Every finding on record at Big Meadows

Based on observation, interview, and record review the facility failed to ensure that food was served at palatable temperatures. This applied to residents reviewed for dining/palatable food which included R33, R37, R66 and the resident council in the sample of 31.The findings include:On 5/12/26 at 10:13 AM, R33 stated she eats in her room and in the dining room. R33 stated her food is served cold all the time.On 5/12/26 at 10:21 AM, R66 stated he eats in his room and his food that is supposed to be warm is cold by the time it gets to him. R66 stated the staff just drop his food tray off and leave. R66 stated he had told staff about and he was not aware he could have staff warm up his food.On 5/13/26 at 8:39 AM, R37 stated that sometimes her hot food is served cold. R37 stated yesterday when she received her lunch tray her ice cream was melted. R37 stated she doesn't know why that is and that she guesses it is just the way it is.On 5/13/26 at 10:34 AM, during the resident council meeting the residents stated that the hot food is served cold sometimes and they don't like it. They stated they were not crazy about the food to begin with and don't like the food to be served cold. They stated the food that is supposed to be warm is served cold in the dining room and for room trays.R33's Minimum Data Set (MDS) dated [DATE] showed no cognitive impairment. R66's MDS dated [DATE] showed no cognitive impairment. The MDS dated [DATE] for R37 showed no cognitive impairment.The February 23, 2026 Resident Council Meeting Notes showed room trays were getting cold food. Residents request the use of insulated covers and to stop using foil. Residents believe the microwave is broken as it does not properly heat food. Food in the dining room is cooling down too fast before being served.The March 16, 2026 Resident Council minutes showed residents stated the room trays were being delivered without the thermal food cover containers.The April 20, 2026 Resident Food Council Minutes showed there were issues with room tray delivery. Residents stated trays are being delivered without the thermal food cover containers. There are delays and other issues with food.On 5/13/26 at 1:41 PM, V1 (Administrator) stated she is currently over the dietary department. V1 stated they have been getting cold food complaints. V1 stated the room trays are all being plated up at the same time and then taken out to the halls, but they cool off because they sit on the rack waiting to be served. V1 stated the hot food should be served hot. The facility's Menu and Adequate Nutrition policy (2026) showed the facility will provide residents with nourishing, palatable and well balanced diets that meet his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident and establish menus based upon this guidance.

Based on observation, interview, and record review the facility failed to ensure an indwelling urinary catheter was maintained in a manner to prevent cross contamination for 1 of 2 residents (R8) reviewed for catheters in the sample of 31. The findings include:R8's face sheet showed he was admitted to the facility 2/26/26 with diagnoses to include cerebral infarction due to embolism of bilateral anterior cerebral arteries dysphagia, hypertension, acute kidney failure with tubular necrosis, hypokalemia, retention of urine, and obstructive and reflux uropathy. R8's facility assessment dated [DATE] showed he has an indwelling urinary catheter. R8's Care Plan initiated 3/3/26 showed, [R8] has an indwelling foley catheter. Observe for any kinds in tubing, that it is flowing properly and positioned correctly at bedside, when up in chair, wheelchair, etc. R8's May 2026 Physician Order sheet showed, . Foley Catheter 16 FR with 30 cc [NAME] to closed drainage system. Diagnosis of Urinary Retention.On 5/12/2026 at 10:47 AM, R8 was sitting in his wheelchair in the activity area. R8's catheter drainage bag was touching the floor, and his tubing was on the floor. On 5/12/2026 at 11:33 AM, R8 was in the dining room sitting at his table. R8's catheter drainage bag was touching the floor, and the tubing was on the floor under his chair.On 5/14/2026 at 9:43 AM, R8 was independently propelling his wheelchair down the hallway near the nurse's station with his catheter bag and the tubing dragging on the floor.On 5/14/2026 at 11:23 AM, V10 (Infection Preventionist) said, The catheter bag should be in a privacy bag and attached to the wheelchair so it is up off the floor. It should not be dragging on the floor for infection control purposes, because residents are already prone to UTIs (urinary tract infections). It should be off the floor for cleanliness and hygiene purposes too. The facility's policy and procedure with revision date of 9/2014 showed, Urinary Catheter Care. Purpose: To provide standard of care for the care and maintenance of indwelling catheters. It is the policy of this facility that the catheter and perineal care will be provided in a manner that will promote and provide cleanliness, acceptable infection control.

Based on observation, interview, and record review the facility failed to ensure footcare including monitoring and treatment was provided after a residents toe was cut during a podiatry visit for 1 of 3 residents (R37) reviewed for foot care in the sample of 31.The findings include:On 5/13/26 at 8:39 AM, R37 stated the doctor cut her toenail too short last time that she had her toenails trimmed. R37 stated there was bleeding to the big toe on the left foot after her toenails were cut. R37 stated she hasn't had her toenails cut since this happened.On 5/13/26 at 1:19 PM, V2 (Director of Nursing/DON) stated she was not aware of R37's toe being cut by the podiatrist and that it wasn't reported to her.On 5/14/26 at 8:30 AM, V2 (DON) stated she investigated R37 and the podiatrist cutting her toe. V2 stated she found a secure conversation written by the nurse to the resident's primary physician on 3/9/26 that showed R37 was seen by the podiatrist, her toenails were clipped, the left big toe was bleeding and wrapped by the podiatrist. The note stated the family wanted to use a Dremel or nail grinder for podiatry visits and asked if it was okay to use. The response from the doctor was to add her to his list. The doctor never said yes or no if it was okay to use the Dremel tool. V2 stated there weren't any treatment orders given for the cut on R37's toe. V2 stated the facility should have reviewed this closer. V2 stated they should have followed up on the secure conversation. V2 stated they should have followed up on what the doctor said and followed up on the visit with the doctor. V2 stated skin checks should have been done and a proper treatment put in place; R37 is diabetic. V2 stated they still don't have the podiatrist's notes from the visit. V2 stated an incident report should have been done after this; V2 stated she did one last night. A secure conversation note dated 3/9/26 for R37 showed she was seen by the podiatrist, her toenails were clipped, and the left toe was bleeding and wrapped by the podiatrist. The family was in to visit and wants to use a Dremel or nail grinder for all podiatry visits. The communication showed the nurse asked if this was okay and asked if the nurse practitioner could look at the resident's toe. The physician responded to add the resident to his list.R37's physician notes showed the doctor did not see her until 4/9/26. The physician's note showed he saw the resident that day for a routine nursing home visit. The note did not show anything regarding her toenails or the cut to her left big toe.The New Skin Alteration Incident that V2 filled out on 5/13/26 for R37 showed on 3/9/26 the podiatrist visited and performed toenail care to the left foot, nicked the resident's left foot and bleeding was noted. R37 witnessed the provider nicking her left great toe during the treatment.The Nurse's Note entered by V2 (DON) dated 5/14/26 for R37 showed her left great toe was assessed on 5/14/26 (two months after the incident) with no open areas noted around the toe. The toenail was noted with black and yellow discolorations under the nail bed of the left great toe. R37 denied pain to the area when it was palpated.The Face Sheet dated 5/14/26 for R37 showed diagnoses including type 2 diabetes mellitus, hypertension, gout, edema, muscle weakness, anemia, and obesity.The Care Plan for R37 dated 2/23/26 did not show any concerns related to foot/toenail care and her diabetes.The facility's Skin Integrity - Foot Care policy (2025) showed it is the policy of this facility to ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health. This policy pertains to maintaining the skin integrity of the foot. The facility will provide foot care and treatment in accordance with professional standards of practice including the prevention of complications from the resident's medical conditions. Medical conditions will be managed and interventions will be implemented in accordance with professional standards of practice to prevent complications of medical conditions. Registered nurses - RN and licensed practical nurses - LPN will participate in the management of medical conditions by following physician orders, assessment of residents, and reporting changes in condition to the resident's physicians. Interventions will be modified in a resident's plan of care as needed.

Based on observation, interview, and record review the facility failed to assess a resident experiencing a change in condition. This applies to 1 of 3 residents (R3) reviewed for changes in condition in the sample of 31. The findings include:R3's admission Record (Face Sheet) showed an admission date of 10/13/25 with diagnoses to include but not limited to heart failure, bipolar disorder, anxiety, and type 1 diabetes. R3's 3/17/26 Quarterly Minimum Data Assessment (MDS) showed she was not comatose, she could hear adequately, she could make herself understood, she could understand others, and she had adequate vision. R3's MDS showed she had moderate cognitive impairment with a Brief Interview for Mental Status score of 8 out of 15 (15 being a perfect score, cognitively intact). The BIMS showed she was able to repeat three words said to her, she correctly answered the month and the day of the week. On 5/12/2026 at 11:40 AM, R3 was in bed, on her back, and in hospital gown. R3 opened her eyes; however, she could not lock eyes and did not respond to any questions. On 5/12/2026 at 12:47 PM, R3 was in the same condition as previously described. R3's 5/12/26 Nurses' Note from 9:13 PM (Authored by V9 Registered Nurse), showed During routine rounds, noted resident to be difficult to arouse, lethargic, confused. She believes she is at her daughter's house. Overall presents with general weakness and fatigue, staying in bed all day, reduced appetite. Able to follow commands with several prompts/cues. Lungs clear throughout. [Vital signs taken] Call placed to POA (Power of Attorney) and he would like her sent to ER (Emergency Room) to be evaluated. [Local] Ambulance dispatched at 2053 (8:53 PM) for altered mental status, transported resident to [local area hospital]. R3's 5/13/26 Nurses note from 4:12 AM showed she returned to the facility at 3:48 AM after .She was given IVF and magnesium as her electrolytes were imbalanced. Res is a/o x 4 (alert and oriented times four; person, place, time, situation), states she feels better. VSS (vital signs stable). Multiple tests performed. No abnormalities found . On 5/13/26 at 1:27 PM, V6 (Registered Nurse) stated R3 took her morning medications on 5/12/26 and R3 was a .little sleepy. On 5/13/2026 at 1:35 PM, V3 (Certified Nursing Assistant/CNA) stated R3 is typically alert and she will answer questions. V3 said V8 (CNA) was R3's day shift CNA on 5/12/26. On 5/13/2026 at 2:02 PM, V8 (CNA) stated she is typically a memory care CNA; however, she does work skilled nursing, and she was familiar with R3 having worked with her a few times prior to 5/12/26. V8 said, .Prior to yesterday, she was a lot better, she had been getting up and going to meals stuff like that, talking, answer questions, and that was as recent as a couple of weeks ago. She goes to the dining room in her wheelchair. Yesterday, she was not responsive. She wouldn't talk much, she wouldn't eat, but I was able to get her to drink a little. How she was yesterday, that was a change in her condition. I did tell the nurse about it and I took her vitals. I told the day nurse a few times I didn't think she was right. I even told the next nurse because I just didn't feel like she was right. The day nurse was [V6 Registered Nurse/RN]. I told her (V6) a few times. She said she would go check on her and I did see her go in there. [V9] was the night nurse and I did tell her and she went down there right away. I told [V9], would you please go down and look at her she is really worrying me today. [R3] did not eat for me at all yesterday. I don't know if this is has ever happened to her before. V8 stated she requested V3 also look at R3 for her opinion and V3 agreed R3 was not at her baseline. On 5/13/2026 at 2:25 PM, V3 stated V8 did request she check on R3. V3 said, .Yesterday was so hectic, but I did go down there with [V8] and see her (R3) and I told [V8] to just keep telling the nurse that something is not right with her. I did agree with [V8] that something was not right. [R3] is normally not like that. How I saw her yesterday, that was a change in her condition. She normally eats without issue. Not eating breakfast, lunch, and dinner is not typical for her. She sometimes skips lunch but not all three meals. On 5/13/2026 at 2:50 PM, V6 stated, regarding 5/12/26, The CNA never told me anything about [R3]. She never asked me to go check on her. On 5/13/26 at 2:40 PM and 5/14/26 at 8:30 AM, V9 (RN) was called, and a message was left. On 5/14/26 at 8:33 AM, a request was made with V2 (Director of Nursing) for her to contact V9 and have V9 return the call for an interview; no return call was made prior to exiting this survey. R3's vital signs showed V8 documented an oxygen saturation and temperature at 6:00 PM. No other vital signs were documented by the day shift on 5/12/26. R3's Progress notes show no documented entries or assessments by V8 or any nurse during the day shift on 5/12/26. R3's May 2026 meal intakes showed she refused all three meals on 5/12/26. The May intakes showed this was the only time this occurred and she only refused two other meals for the month. R3's Assessments heading in the electronic charting showed no documented change in condition or similar assessments for 5/12/26. R3's 2/25/26 Nurses note from 2:38 PM, showed CNA went in to perform AM cares and res (resident) sitting on edge of bed searching for dog. CNA reports res also attempted to push her out of the way with her elbow and then run her w/c (wheelchair) towards her as if to go through her. Res was assisted and brought to breakfast, where she continued to demand her dog and accuse staff of stealing it and hiding it from her. Phoned 911 to send res for eval for altered mental status and acute delusions.Res returned via our transportation at 1400 (2:00 PM). Hospital reports res has UTI (urinary tract infection) and magnesium was low again. R3's 1/17/26 Nurses' Note from 6:04 PM, showed 1545 (3:45 PM) CNA's got resident up for supper. Resident was leaning forward in the w/c, twitching. Resident unable to keep self-upright in w/c. Resident is A&O to self , Resident would answer a question but then fall back to sleep. Notified POA. He agreed to have resident evaluated at the hospital. R3's 1/17/26 Nurses' Note from 7:23 PM showed R3 had a Urinary Tract Infection and her magnesium level was low. The note showed she received intravenous magnesium and an antibiotic. On 5/14/2026 at 11:08 AM, V2 stated if a nurse is notified of a change in condition, they .should go down and do an assessment then notify the doctor, then notify the family. Assessment includes vital signs and a targeted assessment based on the symptoms. V2 said the assessment should be documented in the progress notes. V2 said the day nurse on 5/12/26 should have listened to the CNAs and assessed R3. V2 said the purpose of an assessment is to identify a change in condition as well as gather information to present to the provider so they can make appropriate decisions and determine if the resident requires emergency care.

Based on interview and record review the facility failed to provide shower assistance for a resident dependent upon staff for assistance. This applies to 1 of 3 residents (R25) reviewed for activities of daily living in the sample of 31. The findings include:R25's admission Record (Face Sheet) showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to shortness of breath, depression, and arthritis. R25's 3/5/26 Quarterly Minimum Data Set (MDS) showed he was cognitively intact with a Brief Interview for Mental Status score of 13 out of 15. The MDS showed he required partial/moderate assistance for showering/bathing. On 5/12/2026 at 9:40 AM, R25 stated, .Last Friday (5/8/26) I didn't get a shower and it was about two weeks before I finally got one. Tuesday I get a shave and Friday I get a shower and a shave. It doesn't happen often, but it doesn't happen. They promised me twice on Friday, they promised me at 2:00 PM they would do it then they promised me again at 3:00 PM and I didn't get it. They didn't say anything why I didn't get my shower. They help me in the shower. I have to sit down and shower; I'm afraid I will fall. I like my shower, it makes me feel clean. I only get one or two a week so it's pretty important I get it. I don't have a shower in my room they have to take me to the shower room. I don't refuse my showers I really enjoy them. On 5/14/2026 at 9:22 AM, R25's shower sheets for the previous two months were requested from V2 (Director of Nursing.) On 5/14/2026 at 9:38 AM, V2 provided R25's shower sheets with the most recent being 4/24/26. On 5/14/2026 at 10:06 AM, V3 (Certified Nursing Assistant/CNA) stated the resident shower assignments are posted on the medication room door. V3 stated the shower sheets are placed by the nurses in the medication room. The posted scheduled showed R25's shower days were Tuesday and Friday. On 5/14/2026 at 10:13 AM, V2 stated she had collected all of the shower sheets and what was provided is all that was available. On 5/14/2026 at 11:02 AM, V2 (Director of Nursing) stated most residents are scheduled for two showers a week. V2 said, if a resident refuses a shower, it should be documented on the shower sheet. V2 said, Showers are important. It provides cleanliness, infection prevention, as well as mental and physical wellbeing. The facilities Resident Shower policy showed Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety.

Based on observation, interview, and record review the facility failed to administer insulin in accordance with manufacturer's instructions. This applies to 3 of 3 residents (R6, R38, and R43) reviewed for insulin in the sample of 31. The findings include:1. R6's admission Record (Face Sheet) showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to diabetes type 2, dementia, and depression. R6's May 2026 Medication Administration Record (MAR) showed he received 12 units of long-acting insulin every 12 hours. On 5/13/2026 at 7:56 AM, V6 (Registered Nurse/RN) prepared R6's long-acting insulin multidose injection pen (commonly referred to as an insulin pen). V6 attached the needle to the pen; she did not wipe the rubber seal with alcohol. V6 then dialed the pen to 12 units of insulin. V6 did not prime the insulin pen. V6 then wiped R6's right lower abdomen with an alcohol wipe, held the pen to his skin, depressed the plunger, and held the plunger for less than two seconds. The manufacturer's instructions (revised 5/11/23) showed, .D. Wipe the rubber seal with a new alcohol pad. The instructions showed after the needle is attached, .Always prime a new pen needle before each injection. Turn the white dose knob to 2 dose units. You will hear a 'click' for each unit turned.with the pen upright, press the injection button in until it stops moving and the dose window shows '0'. The instructions continue, Step 6. Inject your dose.press the purple injection button all the way in. The white dose knob will turn and you will hear 'clicks' as you press down. Hold the purple injection button down for 10 seconds after the dose window shows '0'. The facility's Insulin Pen policy showed, .insulin pens will be prior to each use to avoid collection of air in the insulin reservoir. The policy showed, .Attach the pen needle.wipe the rubber seal with an alcohol pad. The policy continued, .Injecting the insulin:. Fully depress the plunger until the dosing numbers count back to zero. While still pressing the plunger, keep the needle in the skin for up to 6-10 seconds and then remove the needle from the skin. 2. R38's admission Record (Face Sheet) showed he was admitted to 1/14/25 with diagnoses to include diabetes type 2, stroke, and weakness. R38's May 2026 Medication Administration Record (MAR) showed a one-time order for 18 units of long-acting insulin to be given on 5/13/26. On 5/13/2026 at 9:33 AM, V4 (Licensed Practical Nurse/LPN) began preparing R38's long-acting insulin. V4 attached the needle to the pen; V4 did not wipe the rubber seal with an alcohol wipe. V4 then dialed the pen to 18 units; V4 did not prime the pen. V4 wiped R38's left-lower abdomen with an alcohol pad, inserted the needle into his skin, depressed the plunger, and injected the insulin. V4 held the plunger for less than 3 seconds. The manufacturer's instructions (dated 11/2022) showed, after a new needle is attached, . Prime your pen. Turn the dose selector to select 2 units. Press and hold the dose button. Make sure a drop appears.Give your injection. Insert the needle.press and hold the dose button. After the dose counter reaches 0, slowly count to 6. 3. R43's admission Record (Face Sheet) showed an original admission date of 5/19/22 with diagnoses to include but not limited to diabetes type 2, dementia, and depression. R43's May 2026 Medication Administration Record (MAR) showed she received 16 units of long-acting insulin daily. On 5/13/2026 at 7:29 AM, V5 (LPN, trainee), began preparing R43's long-acting insulin. V5 attached the needle and turned the dose selector to 16 units. V5 did not wipe the rubber seal or prime the pen. V5 and V4 (LPN) entered R43's room with her long-acting insulin pen. R43 refused insulin at this time. V5 placed R43's insulin pen back in it's pouch. On 5/13/2026 at 10:21 AM, V4 stated R43 had agreed to receive her insulin. V4 removed R43's insulin pen and attached a new needle to the pen. V4 did not wipe the rubber stopper with an alcohol pad. R43's pen was dialed to 16 units from the previous attempt. V4 wiped R43 left lower abdomen with an alcohol pad, inserted the needle into R43's skin, depressed the plunger, and held the plunger for less than 3 seconds before removing it from R43's skin. The manufacturer's instructions (revised 5/11/23) showed, .D. Wipe the rubber seal with a new alcohol pad. The instructions showed after the needle is attached, .Always prime a new pen needle before each injection. Turn the white dose knob to 2 dose units. You will hear a 'click' for each unit turned.with the pen upright, press the injection button in until it stops moving and the dose window shows '0'. The instructions continue, Step 6. Inject your dose.press the purple injection button all the way in. The white dose knob will turn and you will hear 'clicks' as you press down. Hold the purple injection button down for 10 seconds after the dose window shows '0'. On 5/13/2026 at 3:03 PM, V2 (Director of Nursing) stated she expects staff to follow insulin pen manufacturer's instructions. V2 stated the purpose of priming the insulin pen and holding the plunger is to ensure the full dose of insulin is administered. The facility's Insulin Pen policy showed, .insulin pens will be prior to each use to avoid collection of air in the insulin reservoir. The policy showed, .Attach the pen needle.wipe the rubber seal with an alcohol pad. The policy continued, .Injecting the insulin:. Fully depress the plunger until the dosing numbers count back to zero. While still pressing the plunger, keep the needle in the skin for up to 6-10 seconds and then remove the needle from the skin.

Based on observation, interview, and record review, the facility failed to ensure a gait belt was applied and used correctly during a transfer and failed to ensure a bed alarm was turned on for 2 of 2 residents (R37 & R4) reviewed for safety in the sample of 31.The findings include:1. On 5/12/26 at 12:56 PM, V11 (Certified Nursing Assistant/CNA) took a gait belt and put it loosely around R37's lower chest are slightly above her hanging breasts. V11 assisted R37 to transfer from the wheelchair to the toilet and the gait belt moved up under R37's arms. V11 stated that she tries to put the gait belt under R37's breast but sometimes places it on the resident's chest just under her armpits because it is more comfortable. V11 stated R37 transfers with supervision and did not need the gait belt. V11 stated a resident that is a one assist for transfers needs a gait belt.On 5/13/26 at 1:19 PM, V2 (Director of Nursing/DON) stated gait belts should be applied around a resident's waist. The gait belt should not be around the chest and under the residents' arms. That is not appropriate to be up there; the center of gravity would be off. V2 stated R37 was to have a gait belt for transfers for her safety.On 5/14/26 at 2:20 PM V4 (Licensed Practical Nurse/LPN) stated gait belts are applied around the resident at the waist to for support and resident safety.The Care Plan dated 3/6/26 for R37 showed she transfers with 1-2 staff into a wheelchair. R37 does not walk and chooses not to. R37 has a history of a left shoulder dislocation but does not wear a sling any longer.The facility's Use of Gait Belt policy (2025) showed it is the policy of the facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety. All employees will receive education on the proper use of gait belt during orientation and annually.2. On 5/13/26 at 9:25 AM, R4 was on his back in bed. R4 had a bed alarm on his bed that was not turned on. At 9:30 AM V7 (CNA) was called to the room and confirmed that the bed alarm was off and should be turned on. V7 turned the alarm on and stated that an agency nurse had this resident and was told that the alarm needed to be turned on. V7 stated R4's alarm needed to be on for his safety because he gets out of bed. V7 stated that is why the mattress is on the floor because he will fall to his knees.On 5/13/26 at 1:33 PM, V2 (DON) stated R4 should have the bed alarm on when he is in bed and that it is for fall prevention. V2 stated he has had that in place for a long time for his falls. The face Sheet dated 5/14/26 for R4 showed diagnoses including dementia, epilepsy, major depressive disorder, generalized anxiety disorder, hypertension, irritability and anger, history of falling, left artificial knee joint, tear of medial meniscus of right knee, right shoulder rotator cuff complete tear or rupture, osteoarthritis, and failure to thrive.The Care Plan dated 2/18/26 for R4 showed that R4 is at risk for falls related to a history of falls, diagnosis of seizures, and receives psychotropic medications to help manage moods. Sensor pad alarm in bed.The facility's Resident Alarms policy (2025) showed it is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practical level of physical, mental, and psychosocial well-being. The facility shall establish and utilize a systemic approach for safe and appropriate use of resident alarms.implement interventions to reduce risk; and monitor for effectiveness of the interventions and modifying interventions when necessary. When alarms are utilized, additional monitoring shall be provided, including but not limited to: verifying alarms are used in accordance with the resident's care plan. Verifying alarms are working properly.

Based on interview and record review the facility failed to ensure a resident was treated with respect and dignity and not subjected to verbal abuse from a facility employee for 1 of 3 residents (R3) reviewed for Resident Rights and abuse in the sample of 3.The findings include:R3's admission record shows she was admitted to the facility on [DATE]. The quarterly resident assessment and care screening of 11/24/25 documents R3 to have moderate cognitive impairment. The same document shows she is dependent on staff for activities of daily living and for mobility.On 12/6/25 at 1:30 PM, R3 said the incident happened a while ago, and does not recall the exact words, but remembers the girls were nasty towards her while providing care. R3 said the way they spoke to her was disrespectful. She recalled the staff saying, 'Well, if you weren't so old,' just nasty things. I told her to knock it off and she did not listen, and said, 'I don't know why they send you (old) people here.' The facility's investigation showed a statement written by V11 (Certified Nursing Assistant/CNA) on 11/7/25 documented R3 put her call light on around 10:30 PM on 11/7/25 and stated she was not doing well. R3 asked her if the shift had changed and was told the second shift had left the building. V11 documented R3 said the two aides (V4 CNA and V5 CNA) who had been in her room had hurt her. V11 immediately informed the nurse. V11 documented when she received report from V4 (CNA), V4 told her she had said something to R3 along the line of R3 belonging on the (dementia) unit if she keeps digging herself out, and R3 had replied fine then take me there and V4 told R3 Let's go. The investigation showed V4 and V5 denied the events took place. The facility's post-incident follow-up documents that V4 made the comment to V11 she had told R3 she belongs on the (dementia) unit if she keeps digging herself out.The facilities final report states Investigation into verbal abuse is substantiated.On 12/6/25 at 1:30 PM, V1 (Administrator) said on 11/7/25, V4 and V5 were both working the evening shift, and V11 came in at 10 PM to work the night shift. She said R3 reported her concerns to V11 and that V12 (Registered Nurse) also spoke with R3 regarding the issue. V1 said the incident was called to her and an investigation was initiated.Phones calls on 12/6/25 to V11, V4, V5, and V12 were not answered nor returned prior to exit.The facilities Abuse Program Policy states the definition of verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, or their families, or withing their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to; threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again.

Based on observation, interview and record review the facility failed to conduct and document an assessment for a resident following an unwitnessed fall for 1 of 3 residents (R1) reviewed for quality of care in the sample of 3.The findings include:R1's admission record shows he was admitted to the facility on [DATE] and resided on the connection dementia unit. The same document lists his diagnoses including unspecified dementia.The facility's 10/27/25 incident report documents at approximately 7:40 PM R1 was found on the floor. He was lying on his right side in front of the TV. There was a pool of blood at his head, he was yelling and reaching up for help. He denied pain, stating he just wanted to get up. Cold compress to head and was assisted from the floor to a chair with the gait belt. At that time, he complained of right hip pain, unable to bear weight right hip. The Power of Attorney (POA) was notified, and he was sent to the emergency room for evaluation. The note includes vital signs but no range of motion (ROM) or neurological assessment (neuro check) with an obvious head injury.R1's emergency room documents show him to have pain with range of motion to the right hip due to a closed right hip fracture. On 10/30/25 at 9:19 AM, V7 (Licensed Practical Nurse/LPN) said when a resident has a fall, the nurse must make sure there is no injury before they are moved. By moving them it could cause further injury. If the resident is complaining of pain, they should be left in their position until the ambulance arrives. If the fall is unwitnessed, neuro checks are done to ensure they are within normal limits. All the assessments should be documented in the nurse's notes, including ROM and any neuro checks.On 10/30/25 at 12:10 PM, V5 (Certified Nursing Assistant/CNA) said V6 (CNA) had found R1 on the floor and V4 (Registered Nurse/RN) called me into the room. Upon arrival, V4 and V6 had R1 sitting up on the floor. V5 said he took R1's vital signs and helped to clean him up. A chair was moved behind R1 for him to sit in while waiting for the ambulance. He did complain of hip pain anytime we would touch him. He said V4 did check R1s range of motion to his arms and legs, and when his right hip was moved, he complained of pain, but then we still stood him up in the chair, trying to keep the weight off the right hip.On 10/30/25 at 12:30 PM, V4 (RN) said when she arrived to R1's room he had a pool of blood by his head, I assessed the area. He was screaming to get up, but he fell on the floor and no, he should not be moved. V4 said she tried to assess his pupils, but he was not cooperating. He had complaints of pain while he was still on the floor. He said his hip hurt. We were able to transfer him to the ambulance cot without bearing weight on the hip. She said attempts were made to check his ROM while on the floor. V4 said she did not document any of these attempted assessments; they should have been noted in the record. She knew he was being sent to the emergency room. If he was not being sent out, she would have documented more.On 10/30/25 at 11:35 AM, V2 (Director of Nursing/DON) said when a resident has a fall the nurse should complete an assessment. The assessment should include ROM, neuro checks, any indicators of pain, and vital signs. If there are any visible injuries those would also be noted in the assessment along with anything that would be abnormal. After reviewing the progress notes for R1, she said it does not appear the ROM was checked, there is no location of his head injury and no neuro assessment. The ROM would be important because if something is broken, you want the resident to stay in place until the ambulance arrives.On 10/30/25 at 2:15 PM, V1 (Administrator) stated the facility had no specific policy regarding resident assessments after a fall, but the nurse should have documented the ROM and neurologic assessment, or details why it could not be completed.

Based on observation, interview, and record review the facility failed to implement care planned interventions to reduce a dementia resident's anxiety and aggressive behaviors. This failure resulted in R49 fracturing a finger on his left hand after punching a wall. This failure applies to 1 of 9 residents (R49) reviewed for dementia care in the sample of 16. The findings include: A facility incident report dated 2/18/25 showed R49 became agitated during cares and swung out at CNA (certified nursing assistant). While swinging at the CNA, he hit the wall as he was in bed and the bed was pushed up against the wall. X-ray was completed and shows acute fracture of proximal phalanx 3rd finger with mild deformity . R49's admission record dated 8/30/24 showed R49 had diagnoses of anxiety and dementia with behavioral disturbances. R49's behavior note dated 12/20/24 showed R49 started hitting staff, was at the front door hitting the glass after becoming agitated and anxious. R49's behavior note dated 1/7/25 showed, Resident becomes very anxious, sometimes agitated and restless around 6 or 7 pm almost every night . R49's current care plan showed, The resident is/has potential to be physically aggressive due to not understanding need for help with ADLs (activities of daily living) related to dementia . The care plan showed behavioral interventions for R49 as resident's triggers for physical aggression are wanting to be left alone. The resident's behaviors is de-escalated by offering a (brand name soda) or calling son . When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. The care plan showed R49 was cognitively impaired. On 2/24/25 at 9:30 AM, R49 was seated in a recliner in his room. R49's second, middle, and ring fingers on his left hand were swollen and bruised. When R49's was asked what had happened to his left hand, R49 stated, I don't know. On 2/24/25 at 12:52 PM, V4 (CNA) stated she was the CNA providing cares to R49 on 2/18/25, at the time of the incident. V4 stated, It (the incident) happened sometime in the middle of the night. His CNA had gone on lunch break, so I was watching that assignment while she was gone. I knew (R49) had a history of yelling and hitting but I didn't know at that time that he had been having behaviors all night. His CNA didn't report he had been having behaviors to me before she went on lunch. V4 stated she heard R49's safety alarms going off, so she entered R49's room. She found R49 seated on the side of his bed. R49 was incontinent. V4 stated, I helped him lay down in bed so I could change him. I rolled him on his side (on his bed). He never said anything but that's when he started punching the wall. I probably should have given him a break. I was in the middle of changing him, so I just kept trying to get him changed. He continued to swing with his arm. That's when he hit me too. He punched me while I was trying to get his brief on. V4 stated she was unaware that R49 had injured his left hand at the time. On 2/25/25 at 10:30 AM, V7 (CNA) stated she was R49's assigned CNA on 2/18/25. V7 stated on 2/18/25, R49 had been having verbal and physically aggressive behaviors that evening prior to the incident. V7 stated, He was cussing at me. He threatened my job. He tried to hit me when I changed him Usually, if you let him settle down and re-approach him, he will settle down . V7 stated she did not inform V4 (CNA) that R49 had been having behaviors that night prior to V7 taking a break for lunch. V7 (CNA) stated, I just assumed everyone knew (R49) had been having a bad night. On 2/24/25 at 1:19 PM, V5 (Social Services Director) stated, (R49's) behaviors stem from him wanting to be left alone, his confusion and him being hard of hearing. He has had physical behaviors of kicking and hitting but they are usually because he wants to be left alone . If he is having behaviors, it's best for staff to leave him alone and re-approach later. I have told staff that if he safe and is having behaviors, walk away and re-approach after he calms down. Calling his son or offering him a (brand name soda) also helps to calm him down. On 2/25/25 at 11:07 AM, V6 (Physician of R49) stated R49 was admitted to the facility because of his dementia and his family could not manage him at home. V6 stated, All staff should be aware of the different strategies to de-escalate a resident's dementia related behaviors as per their care plan. The goal is to use non-pharmacological behavioral interventions first . The facility's Behavioral Management policy (undated) showed, It is the goal to provide a Behavioral Management Program that will differentiate the diagnosis of behavioral symptoms so that the underlying cause of the symptom is recognized and treated appropriately . Procedure: Develop a Behavior Management Program, if appropriate, with identification and implementation of interventions . All residents of Behavior Monitoring/Management should have interventions noted on the individual resident's care plan .

Based on observation, interview, and record review, the facility failed to provide meaningful activities to dementia residents for 4 of 10 residents (R39, R30, R45, R36) reviewed for activities in the sample of 16. The findings include: 1. R39's Physician Order Sheet (POS) dated 2/25 show R39 has diagnosis of dementia. R39's care plan with review date of 1/21/25 documents, R39 prefers individual 1:1 activities, at times may observe/join a group activity. R39 enjoys walking halls, relaxing in his room, common area, reminiscing, watching TV, visiting with family, listening to music, going outdoors, observing dice/card games, bingo, painting arts and crafts. On 2/23/25, At 10AM, 11AM, 11:37 AM and 12 PM, R39 was up and down the hallways wandering back and forth on both E and F wings in the Dementia Unit. Staff were saying hi to R39. R39 would enter other resident's room, then staff would redirect R39 don't go in that room. R39 was not offered to engage in any activity. R39 had lunch around 12:30 PM. Then at 1PM, 1:30 PM, 2PM and 2:30 PM, R39 continued to wander up and down the hallways. V11 (Registered Nurse/RN) and R39's nurse said this is what he (R39) does all day, walk back and forth aimlessly in the hallways. V11 stated Today is Sunday, we do not offer activities on the weekend. On 2/24/25 at 10AM, 11AM and 12PM, R39 again was up and down the hallway walking back and forth in the Dementia Unit. No staff attempted to engage R39 in any activity including group activities. V9 and V16 (both Certified Nursing Assistant/CNAs) said (R39) gets too tired walking around all day so he wakes up late in the morning then wanders again. 2. R30's activity care plan dated 1/21/25 show, R30 has a diagnosis of dementia and diabetes. R30 needs reminder as to when and where an activity is taking place. R30 enjoys listening to music, Bingo, snack, and chat, observing games, relaxing in room/common area, watching TV, reminiscing, going outdoors, family visits, etc. R30's Activity Interview for daily and activity preferences dated 1/16/25 show, it was important for R30 to get fresh air when the weather is good, and it was important to participate in religious activities. On 2/23/25 at 9:20 AM, 10 AM, and 11 AM, R30 was sitting in a recliner in the common area by the dining room in the Dementia Unit. R30 was just looking around. R30 said hi to this surveyor. At 12PM, R30 was now asleep in his recliner in the common area. There were no ongoing activities. This surveyor asked V14 (CNA) who was in the common area if she was doing any activities with the residents this Sunday. V14 said she was assigned as the Dining room CNA assisting with meals. V14 said she was not an activity aide. Both V12 and V13 said they were the CNAs on the Dementia unit, (E and F wings) and they were not running activities this Sunday they were working as CNAs. The February Activity Calendar in the Dementia Unit for Sunday 2/23/25 show 1:1 activity. There were no ongoing 1:1 Activity at that time. 3. R45's POS show R45 has diagnoses that include dementia and COPD. R45 wears on oxygen. R45 was alert and able to verbalize his needs. R45's Activity Interview for daily and activity preferences dated 2/6/25 show, it was important for R45 to listen to music, it was important to keep up with the news, it was important to go out for fresh air when the weather is good. On 2/23/25 (Sunday) at 11:45 AM, R45 was in his room watching TV. R45 said there was nothing to do but watch TV in his room. On 2/25/25 at 9:15 AM, R45 said no one comes around and invite him to activities. I would go or just bring me something to do here in my room. On 2/24/25 at 1:14PM, V15 (Activity Director) said she had no Activity Aide to help her. She was the only Activity staff in the Dementia Unit working Monday to Friday. If she was doing group activities, there were no staff providing 1:1 activities. Activities are important to demented residents, it gives them something to do, it keeps them busy. On 2/24/25 at 2PM, V8 (Dementia Care Director) said she will work with V15 to improve the Activity being offered to the dementia resident in the Dementia Unit. V8 said she will discuss with the management regarding Activity Aides on weekends. On 2/24/25 at 3PM V1 (Administrator) said there was a lot for 1 person in the dementia unit to do Activities, we are working on offering activities 7 days a week. 35541 4. R36's current care plan showed R36 was admitted to the secured dementia unit in the facility on 10/29/22 due to his diagnoses of dementia and confusion. The care plan showed R36 enjoyed going outdoors and listening to music. R36's care plan showed, Encourage participation in the following activities, exercise, active games, socials, special events . Assist resident with set up of independent leisure activities as needed . Provide verbal reminders and encouragement to activity programming .Distract (R36) from wandering by offering pleasant diversions, structured activities, food, conversation, television, book . R36's activity assessment dated [DATE] showed it was important for him to listen to music, be around pets, keep up with news, go outside, and do activities with groups of people. On 2/24/25 at 8:59 AM, R36 stood by the locked exit door of the dementia unit. R36 was knocking on the window of the door, saying he wanted to go to the river. On 2/24/25 at 9:01 AM, R36 continued to knock on the window of the exit door of the dementia unit. On 2/24/25 at 9:08 AM, R36 was observed walking back and forth by the exit door of the dementia unit. R36 would look out the window of the door and then walk away. On 2/24/25 at 10:08 AM, a staff member was painting the fingernails of a female resident on the dementia unit. Four residents were asleep in the television lounge. Two nonverbal female residents were seated at a table, picking up plastic flowers. R36 paced up and down the hallway of the dementia unit. He would stop at times to look out the window of the exit door of the unit. No staff spoke to R36 and/or attempted to engage R36 in an activity. On 2/24/25 at 10:29 AM, R36 continued to pace up and down the hallway of the dementia unit. R36 walked into the dining area and asked V9 (CNA), What's for lunch today? V9 replied, It's not time yet. R36 shrugged his shoulders and stated, I guess I will go watch TV then. V9 did not respond to R36. V9 made no attempt to engage R36 in an activity and/or ask R36 what he would like to do. On 2/24/25 at 10:37 AM, R36 walked back into the dining area of the dementia unit. R36 asked V9, What time is lunch? V9 stated, 12:30. V9 made no attempt to engage R36 in an activity and/or ask R36 what he would like to do. R36 walked out of the dining area. The facility's Activities policy (undated) showed, The facility will provide a comprehensive activity program designed to promote resident well-being and quality of life, which includes a variety of activities that address physical, cognitive, social, emotional, and spiritual needs. Residents will be given the opportunity to choose activities based on their interests and abilities, and staff will actively encourage participation while respecting resident autonomy to decline activities . Staff responsibilities: Trained staff to lead and facilitate activities. Monitoring resident participation and providing assistance as needed .

Based on observation, interview, and record review the facility failed to follow the pureed menu for 8 of 8 residents (R1, R2, R7, R11, R13, R18, R33, and R46) reviewed for pureed menu in the sample of 16. The findings include: A facility provided list printed on 2/24/24 showed R1, R2, R7, R11, R18, R33, and R46 were on a pureed diet. The same list showed R13 was on a liquidized pureed diet. The pureed menu for 2/24/25 showed residents on pureed and liquidized pureed diets were to receive pureed BBQ turkey, pureed creamed corn, pureed cornbread, and pureed cake. On 02/24/25 at 10:02 AM, V20 (Cook) was observed making the pureed meal. V20 pureed the BBQ turkey, creamed corn, and dessert. V20 was not observed making pureed corn bread nor was corn bread added to the BBQ turkey or creamed corn. On 02/24/25 at 11:17 AM, V20 started to plate the pureed meal. There was no container of pureed cornbread on the serving steam table. V20 plated R1, R7, R11, and R13's pureed meals by serving them pureed BBQ turkey, pureed creamed corn, and pureed dessert. R1, R7, R11, and R13 did not received pureed cornbread as indicated by the menu. On 02/24/25 at 01:10 PM, R33 was served a room tray. The tray contained a bowl of pureed BBQ meat, a bowl of pureed creamed corn, a bowl of chocolate dessert and four glasses of assorted beverages that were honey thick. There was no pureed corn bread present. On 02/24/25 at 11:50 AM, V21 (Dietary Manager) said the menu should be followed. On 02/25/25 at 09:39 AM, V21 said pureed corn bread was not served.

Based on interview and record review the facility failed to ensure a facility bed hold policy was in the resident packet of information for a resident who was transferred to the hospital for 1 of 1 resident (R33) reviewed for hospitalization s in the sample of 16. The findings include: The facility' census list for R33, shows on 2/16/25, R33 was transferred out to the hospital. R33's progress noted dated 2/16/25, shows R33 had a change in condition where her oxygen saturations dropped to 86 percent. The nurse practitioner was notified with orders to send to emergency room for evaluation. R33's POA was notified, paperwork was faxed to the hospital. On 2/25/25 at 8:26 AM, V17 (Registered Nurse) stated there is a packet of paper which goes with resident to the hospital, face sheet, POA paperwork, insurance, POLST, meds and diagnoses. We fax the packet to the hospital, and we give the packet to EMS (Emergency Medical Services). V17 was not sure if bed hold went with resident. V1(Administrator) would know. V17 showed this surveyor the packets of information which went with the residents. There was no bed hold policy included in the packets. On 2/25/25 at 11:10 AM, V1 (Administrator) stated the bed hold policy is on a clipboard next to the binders with the resident packets of information. The nurses are to pull one and include. V1 stated she had no evidence to show the bed hold policy was sent with R33 for her emergent transfer to the hospital. V1 stated they used to include in the packet, but the packets were getting too thick, so the bed hold was removed from the resident packets. The facility's Bed Hold Policy and Readmission (undated), shows, in case of emergency transfer, notification of the family or legal representative is provided with written notification within 24 hours of transfer, the resident's copy of the notice is sent with other papers accompanying the resident to the hospital.

Based on observation, interview, and record review the facility to ensure speech therapy recommendations were implemented for a resident with moderate oral/pharyngeal dysphagia. This applies to 1 of 3 residents (R161) reviewed for safety in the sample of 16. The findings include: On 2/23/24 at 12:45 PM, a sign posted on R161's door for droplet/contact precautions. R161 was in her room lying in bed at approximately 30 degrees. R161's noon meal on her bedside table included country fried steak cut up, veggies and mashed potatoes. R161's diet card lists a regular diet. On 2/24/25 at 12:50 PM, R161 was in her room lying in bed at 30 degrees. Her noon meal on her bedside table included a BBQ pork sandwich, corn, and coleslaw. Regular liquids on her bedside table. On 2/24/25 at 12:58 PM, V8 (Licensed Practical Nurse) said R161 has not been doing well, she has influenza and was recently sent out to the hospital and has been declining. She is on a regular diet, has poor appetite and is not aware of R161 having any problems swallowing. On 2/25/25 at 9:54 AM, V1 (Administrator) said speech therapy was here on 2/23/25, she wrote the recommendations and gave it to the director of therapy instead of nursing. The recommendations to downgrade her diet and nectar thick liquids did not get followed through. R161's Physician Order Sheets dated February 2025 shows orders for regular diet. ST evaluation completed .recommend diet downgrade to mechanical soft consistency and nectar thick liquids (order date 2/23/25). R161's Speech Therapy Evaluation and Plan of Treatment report dated 2/23/25 shows new onset of coughing/choking during oral intake (R161) presents with moderate oral/pharyngeal dysphagia .recommendations include mild thick liquids, minced and moist diet and mechanical ground textures. Swallowing strategies including alternate liquid/solid, bolus size modifications and rate modifications, upright during meals, and upright posture for 30 minutes after meals. The facility's undated Management of Dysphagia Policy states, dysphagia, or difficulty swallowing can be caused by various factors and requires appropriate management to prevent complications such as aspiration pneumonia and malnutrition. Dysphagia precautions include dietary guidelines, safe swallowing techniques and staff training.

Based on observation, interview, and record review the facility failed to ensure a resident's adaptive equipment was functioning for 1 of 9 residents (R10) reviewed for restorative in the sample of 16. The findings include: On 02/23/25 at 11:16 AM, R10 was sitting in his wheelchair near the nurse's station. His left arm was dangling next to his side. The wheelchair arm trough attached to the left wheelchair arm was bent over with the bottom of the trough facing away from the resident. R10 stated he does not use it (arm trough) because it was broken. It had been broken for a few months. He told the staff and they said they would fix it, not sure when that is going to happen. R10 explained he had a stroke which affected his left side. R10 then proceeded to self-propel himself using his right foot down the hallway. R10's Facility assessment dated [DATE] shows diagnoses to include stroke and hemiplegia. R10's has impaired range of motion on his left side and is cognitively intact. R10's current care plan shows R10 has impairment on his left arm and left leg. On 02/25/25 at 10:00 AM, V22 (Restorative) stated R10 uses the arm trough for comfort and positioning. V22 was not aware adaptive device was broken. This surveyor went with V22 to R10's room. R10 was lying in his bed and his wheelchair was in the bathroom. R10 stated his arm keeps falling off it (trough). V22 inspected the arm trough and stated the trough was to the side and was not positioned correctly for the resident to use. She looked at the trough further and stated this trough does not go with this wheelchair. I will talk with maintenance and see if there is an arm trough which fits the chair. At 11:05 AM, V22 stated she found an arm trough in the medical supply catalog and will get with maintenance to find one which will fit R10's wheelchair so they can get it ordered. A facility policy on the use and/or care of adaptive equipment was requested. The administrator stated they did not have one.

Based on observation, interview, and record review the facility failed to ensure staff implemented enhanced barrier precautions to prevent the spread of infection for 2 of 16 residents (R2, R45) reviewed for infection control in the sample of 16. The findings include: 1. On 2/24/25 at 9:22 AM, there was no sign posted on R2's door for enhanced barrier precautions. V24 (Certified Nursing Assistant/CNA) donned gloves and did not wear a gown while providing incontinence care to R2. An open pressure ulcer was observed on R2's coccyx. On 2/24/25 at 2:03 PM, V3 (Assistant Director of Nursing/Infection Control Preventionist) said R2 was on isolation for influenza, and they discontinued her isolation. She said R3 has a wound and should be on enhanced barrier precautions, staff should wear gown and gloves when providing direct care. R2's Physician Order Sheets dated February 2025 does not show orders for enhanced barrier precautions. The P.O.S. shows orders for treatment orders for right coccyx wound. 33760 2. On 02/23/25 at 9:15 AM, R45 was in his room alert and pleasant. An Enhance Barrier Precaution (EBP) sign was posted inside his room. V11 (Registered Nurse/RN) and V12 (CNA) both said R45 has a urinary catheter and uses a leg bag at daytime. R45 pointed to his leg and said yup, it's here. On 2/24/25 at 10:05 AM, R45 was being assisted for his leg bag. V16 (CNA) was wearing gloves but was not wearing any gown. V16 said when R45 woke up this morning, V16 disconnected R45's indwelling urinary bag then connected R45's leg bag. R45 said she had gloves on. On 2/24/25 at 2:20 PM, V17 (RN) confirmed that R45 was on EBP due to his urinary catheter. Staff should use gown and gloves when providing catheter care. R45's Physician Order Sheet (POS) printed on 2/24/25 documents, Enhanced Barrier Precautions r/t indwelling Foley. May be discontinued if Foley is no longer needed. dx: urinary retention The facility Enhance Barrier Precaution undated documents, It is the policy of this facility to implement enhance barrier precautions for the prevention of transmission of multidrug organism targeted by the CDC. c. Clear signage will be posted on the door or wall outside of the resident's room indicating the type of precaution, required PPE and the high-contact resident care activities that require the use of gown and gloves. 4. High contact resident care activities include: a. wound dressing g Device care use: urinary catheters .

Based on observation, interview, and record review the facility failed to transport a resident in a wheelchair with her feet on the foot pedals. This failure resulted in R1 sustaining a fracture to her right femur. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. The findings include: R1's Admission Record (Face Sheet) showed an original admitted [DATE] with diagnoses to include: cervical vertebra fracture (bones in the neck, was her admitting diagnosis), osteoporosis (decreased bone strength) without current pathological fracture (no fractures due to her osteoporosis), arthritis, cognitive communication deficit, lack of coordination, difficulty in walking, lack of coordination, need for assistance with personal care, and adult failure to thrive. The facility's final incident report submitted on 2/14/24 showed .it appears that [R1] moved her foot from the foot pedal while being assisted from the dining room causing her foot to touch the floor. The staff member stopped immediately when this happened and called the nurse stat. The report showed an x-ray was ordered and she sustained a nondisplaced, periprosthetic distal femoral fracture (fracture of the thigh bone near the knee and around her knee replacement hardware). On 2/22/24 at 12:30 PM, V1 (Administrator) stated the facility's recorded video footage from 2/13/24 was fast by 15 to 20 minutes. On 2/22/24 at 12:07 PM, recorded video footage from the Main Dining Room camera was reviewed. The footage showed on 2/13/24 at 6:17 PM, R1 was seated at a dining table with two other residents. R1 was seated at a dining table near the dining room door with her right side facing the door and her left side facing the camera. V11 (Dietary Aide) approached R1, unlocked R1's wheelchair, pulled her away from the table and took her out of the dining room. R1 had a blanket covering her lower half, which extended to cover most of her feet and the foot pedals. Also, R1's feet were not visible under the dining table. V11 did not stop and adjust R1's feet or have R1 adjust her own feet after she pulled R1 away from the table. V11 did not pull back R1's blanket to fully expose the foot pedals or R1's feet. On 2/22/24 at 12:22 PM, recorded video footage from the Lobby Front cameral was reviewed. The video footage from 2/13/24 showed a close view of the dining room entrance and the front lobby entrance. R1's dining table was just visible. As V11 pushed R1 out of the dining room doors (10 feet at most from her dining table), the toes of R1's right foot is visible, most of her left foot is visible, and the front edge of the foot pedals are visible. The soles of R1's feet are not on the pedals. R1's feet are in between the foot pedals. The right side of R1's right ankle is resting on the right foot pedal. Most of R1's right foot is below the foot pedal. On 2/22/24 at 11:54 AM, recorded video footage from the Multi room [ROOM NUMBER] camera was reviewed at one quarter speed and was viewed several times. The video from 2/13/24 at 6:17 PM showed the hallway leading from the main entrance/dining room area to the resident hallways; however, the dining room and main entry were not visible. The video showed V11 pushing R1 in her wheelchair down the hallway. At approximately 20 feet from the dining room door, R1's foot touched the floor; her leg raised up as her foot started to go behind and under her; R1's upper body lunged forward; V11 grabbed R1's left shoulder and pulled her back into the wheelchair; V11 stopped the wheelchair; and pulled the wheelchair backwards 1 to 2 feet. During this incident, there was no indication R1 lifted her leg off the pedal; the only movement of her leg was straight down to the floor then her knee raised up after her foot touched the floor. V11 then got on her radio and R1 pulled the blanket off her right leg. R1's right leg and foot were under the seat of the wheelchair. Nursing staff arrived, placed R1's foot on the pedal, and pushed R1 down the hallway and out of view of the camera. On 2/22/24 at 12:30 PM, V1 stated, while viewing a still image of the Lobby Front video footage, she agreed, the soles of R1's feet were not firmly planted on the foot pedals of the wheelchair. On 2/22/24 at 3:10 PM, V11 (Dietary Aide) stated she was allowed to push residents in wheelchairs if the resident had foot pedals. V11 stated she was educated the residents feet needed to be on the foot pedals. V11 stated R1's feet were on the foot pedals the evening of 2/13/24. V11 stated as she pushed R1 down the hallway, . I saw her lift her leg, I slowed down, her leg dropped, she said 'Ow', I stopped, and I called the nurses. V11 stated she did not have to tell R1 to put her feet on the foot pedals because they were already on the foot pedals. V11 said, I could see the tops of her feet out the front of the quilt. I couldn't see the foot pedals that well. R1's Progress Notes showed a communication was sent to V15 (R1's Physician) on 2/13/24 at 9:53 PM stating, Resident had incident today after dinner where she had bumped her left knee [was later corrected to right knee] causing severe discomfort and affected mobility. She stated she had a knee replacement in this knee and reported pain at 10/10 (10 out of 10). She continues to report pain and thinks her knee was twisted during incident with her wheelchair. She is requesting x-ray to left knee to rule out fracture. R1's X-ray results for her right knee, sent to the facility on [DATE] at 2:54 PM, showed an acute (sudden or recent onset) nondisplaced (the bone remained in alignment) periprosthetic (fracture around the knee replacement hardware) distal femoral fracture (fracture of the thigh bone at the area just above the knee). The X-ray report showed a handwritten note which stated V15 (R1's Physician) ordered a knee immobilizer on at all times until she's seen by ortho (orthopedics). R1's February 2024 Medication Administration Record (MAR) showed, prior to the incident on 2/13/24, R1 took as needed pain medication (oxycodone, narcotic pain medication) twice, once on 2/9/24 and again on 2/11/24. The MAR showed after the incident on 2/13/24 R1 was given 6 doses of as needed pain medication from 2/13/24 through 2/15/24. On 2/22/24 at 1:02 PM, V8 (Licensed Practical Nurse) stated she was one of the nurses who responded to R1 on 2/13/24. V8 stated prior to this incident R1 did not complain of pain to her right leg. V8 stated R1 was admitted to the facility with a cervical fracture and her pain was pertaining to that fracture. V8 stated when she responded to the incident, R1 was complaining of soreness to her right leg and when R1's leg was placed back on the foot pedal she said ow. V8 said the soles of a resident's feet should be firmly planted on the foot pedals of the wheelchair. V8 said if a resident's feet are not firmly planted there is a risk the persons foot could fall off and go behind them. On 2/23/24 at 9:32 AM, V20 (Certified Nursing Assistant/CNA) stated prior to this incident R1's transfer status was an extensive assist of 2 with a gait belt. (A belt wrapped around the person used by staff to steady and support the resident.) V20 said after the incident R1 required a mechanical crane-type lift for transfers. V20 said, after the incident on 2/13/24, R1 was crying out in pain during mechanical lift transfers. V20 said this pain was new for R1. V20 said she did not believe, given R1's transfer status prior to 2/13/24, R1 would have had the strength to support her legs during a wheelchair transfer. On 2/27/24 at 10:58 AM, V2 (Director of Nursing) stated regarding transporting residents in wheelchairs, Prior to this [incident] people were not trained on how to transport residents in a wheelchair, but we are fixing that I was aware that there is a possibility of injury with wheelchair transportation. The type of injuries is bumping into them, dropping leg, grabbing the wheels and getting their arms wrapped up in the wheelchair. V2 said interventions to prevent injury from a foot dropping would be, making sure pedals are in place and make sure feet are on the pedals. The feet are firmly planted in place on the pedal prior to moving the resident. I was told a member from dietary was pushing her out of the dining room and she had some pain in her leg and the dietary aide stopped and called for staff. V2 reviewed a still image of the incident on 2/13/24 at 6:17 PM. V2 stated, .it does look like the ankle is resting on the side of the pedal. If I was the one transporting her or I saw someone transporting her like that in that position, I would have stopped her and put her feet on the pedal. On 2/22/24 at 4:01 PM, V1 stated the facility does not have a policy discussing the transportation of residents in wheelchairs except for Assist in the evacuation of residents. The facility's Dietary Aide Job Description (not dated) did show resident transportation in the job description. The facility's Certified Nursing Assistant Job Description (not dated) showed .Assist in transporting residents to/from appointments, activity and social programs, etc. as necessary. Assist with lifting, turning, moving, positioning, and transporting residents into and out of beds, chairs, wheelchairs, lifts, etc .

Based on observation, interview, and record review the facility failed to manage a resident's (R1) pain when she was known to have a fractured leg and she was transferred without her immobilizer. The facility also failed to provide pain medication for resident (R1) with fractured leg prior to transferring her out of bed. This failure resulted in R1 experiencing excruciating pain. This applies to 1 of 3 residents reviewed for pain in the sample of 3. The findings include: R1's Admission Record (Face Sheet) showed an original admitted [DATE] with diagnoses to include: cervical vertebra fracture (bones in the neck, was her admitting diagnosis), osteoporosis (decreased bone strength) without current pathological fracture (no fractures due to her osteoporosis), arthritis, cognitive communication deficit, lack of coordination, difficulty in walking, lack of coordination, need for assistance with personal care, and adult failure to thrive. The facility's video footage showed on 2/13/24 at approximately 6:00 PM (time was adjusted due to inaccuracy of the camera timestamp) V11 (Dietary Aide) unlocked R1's wheelchair and wheeled her out of the dining room. During the transfer, R1's foot contacted the floor and went under her seat. V11 stopped, backed the wheelchair up, and called for assistance. R1 had a blanket covering the lower half of her body. R1 pulled the blanket back and exposed her right leg. On 2/27/24 at 9:45 AM, V13 (Registered Nurse) stated she responded to V11's call for assistance. V13 stated when she placed R1's foot on the wheelchair pedal she noticed R1 was experiencing some discomfort. V13 stated, R1 had a history of a knee replacement and R1 was concerned about that knee because she tweaked it during the transfer. V13 stated she worked on 2/13/24 from 2:00 PM till 6:00 PM and she requested an X-ray before leaving her shift. R1's X-ray results for her right knee, sent to the facility on [DATE] at 2:54 PM, showed an acute (sudden or recent onset) nondisplaced (the bone remained in alignment) periprosthetic (fracture around the knee replacement hardware) distal femoral fracture (fracture of the thigh bone at the area just above the knee). The X-ray report showed a handwritten note stating V15 (R1's Physician) ordered a knee immobilizer on at all times until she's seen by ortho (orthopedics). The order showed it was taken at 3:15 PM on 2/14/24. The X-ray report showed V4 (R1's Daughter-in-Law and the spouse to R1's Power of Attorney/V3) was going to get the immobilizer. The facility's schedule for 2/14/24 showed V10 (Certified Nursing Assistant/CNA) was assigned to R1's hall from 6:00 AM to 2:00 PM. On 2/22/24 at 3:35 PM, V10 stated, regarding her shift on 2/14/24, R1 was experiencing excruciating pain. V10 said, She (R1) likes to sleep on her side, but we tried to repo (reposition) her, and she cried out in pain when we moved her .We did tell the on-coming CNAs that she was having a lot of pain with any movement. V10 said she did not transfer R1 out of bed her entire shift due to R1's pain with movement. On 2/22/24 at 3:44 PM, V9 (CNA) stated she worked 6:00 AM to 6:00 PM on 2/14/24. V9 stated, regarding R1's transfer the evening of 2/14/24, We talked her into getting up for dinner. She hollered out in pain, but we talked her through it. I think it was her right leg. She was hesitant to get up. The nurses did not say don't transfer her. I heard there was a fracture of the knee, so we tried to support it during the transfer .She didn't refuse the transfer even when she was screaming; she didn't say to stop . On 2/23/24 at 9:32 AM, V20 (CNA) stated she assisted with R1's transfer the evening of 2/14/24. V20 said, I did transfer her (R1) out of bed the next day for dinner because she wanted to go eat dinner. During the transfer, she did cry out in a lot of pain. We asked the nurse if it was okay to transfer and she said it was okay and she said to be very careful, which is why we used the (mechanical crane-type lift). That was my first time transferring someone with a fresh fracture. She was yelling out in pain, we offered to lay her back down, but she just wanted to go eat. Even rolling her she was in a lot of pain. If I was told by the nurse not to transfer her, I would not have transferred her. I was not there when the family came in with the immobilizer to transfer her back to bed. (The following interviews with R1's family were conducted as a group interview on 2/22/24 at 10:12 AM. In attendance were, V3 (R1's Power of Attorney/Son); V4 (R1's Daughter-in-Law and spouse to V3); V5 (R1's Daughter); V6 (R1's Son); V16 (R1's Daughter-in-Law and spouse to V6); V17 (R1's Son); and V7 (R1's Daughter.) On 2/22/24 at 10:12 AM, V4 (R1's Daughter-in-Law) stated she was a Registered Nurse. V4 stated she came to the facility on [DATE] to measure R1 for the knee immobilizer. V4 stated R1 was in bed at that time. V4 stated she returned that evening, around 6:00 PM, with the immobilizer and R1 was in the wheelchair. V4 said, I can't believe they moved her from the bed to the wheelchair with a fracture and without the immobilizer. They knew she had a new fracture at that point and the moved her anyway. V4 stated she was unable to apply the immobilizer with R1 in the wheelchair so we (mechanical crane-type lift) her back to bed. V4 stated the transfer back to bed .was the most horrible thing I have ever seen; I really don't want to talk about. V4 stated, R1 was crying and screaming with pain during the transfer back to bed. On 2/22/24 at 10:12 AM, V5 stated she is a Physical Therapy Assistant. V5 stated she was contacted by V4 regarding R1's transfer the evening of 2/14/24. V5 said, They never should have transferred her. When [V4] told me that I called and spoke to the nurse .I think it was [V13 Registered Nurse] and I told her do not transfer her [R1]. I told her put a note in the chart or do whatever you have to, but do not transfer her and we would be in the next morning to have her sent to the ER for evaluation. [V4] came in the next morning and they had transferred her into a wheelchair. On 2/22/24 at 10:12 AM, V4 stated, I came in the next morning, and they had transferred her to a wheelchair. I had had enough and said let's send her out. I could not be in the room to watch them transfer her from the wheelchair to the bed. It was such a horrible event from the day before. I couldn't watch her go through that again, but I could hear her scream in pain through the door. If they had left her in bed, she would have had much less pain when she was transferred to the cot for EMS transport. On 2/27/24 at 9:45 AM, V13 (RN) stated she had numerous conversations with R1's family. V13 denied being told she should not transfer R1. On 2/23/24 at 12:11 PM, V18 (CNA) stated she worked on 2/13/24 and 2/14/24 from 6:00 PM to 10:00 PM. V18 stated she did not transfer R1; however, she assisted the family with applying R1's immobilizer (evening of 2/14/24). V18 said, R1 was having quite a bit of pain. V18 said, Her Daughter-in-Law said let's keep her in bed the next couple of days . V18 stated We passed it on in report that she should stay in bed, and I think one of the nurses was in the room when the daughter told us that, but I don't remember which one was in the room. The daughter wanted to keep her in bed the next couple of days because (R1) was yelling out with pain with the slightest bit of movement. She would say ow if you rolled her but, the amount of pain she was having was more than she normally had. I was not used to her screaming out in pain; it broke my heart. On 2/22/24 at 2:30 PM, V12 (Assistant Director of Nursing) stated she was R1's nurse on 2/14/24 from 6:00 AM to 6:00 PM. V12 stated the CNAs did transfer R1 to the wheelchair for dinner the evening of 2/14/24. V12 stated it was not discussed if R1 should not be transferred and she did not tell the CNAs to keep R1 in bed. V12 said the purpose of the immobilizer is to .keep it (her leg/knee) from moving and hurting her . On 2/23/24 at 9:15 AM, V21 (CNA) stated she transferred R1 the morning of 2/15/24 from the bed to the wheelchair then back again. V21 said, .Yes, she was yelling out in pain. She kept saying, 'my leg, my leg.' But once we got her in the chair, she was comfortable .Her daughter showed up. The daughter said she had to step out for the transfer to bed because she couldn't stand to see her like that .She was yelling out in pain for the transfer to the bed. And then after the transfer she was grimacing in pain, so we tried to prop up her leg. I was never told not to transfer, I actually asked if we should transfer her. Sometimes the family will request not to get her up. I asked [V14 Registered Nurse] if we should get her up . On 2/27/24 at 9:44 AM, V14 stated she was not in the room for R1's transfer to the wheelchair or back to bed. V14 said, R1 was transferred out of bed sometime on 2/15/24 between 7:30 AM and 8:00 AM. V14 said, the CNAs brought R1, in the wheelchair, to her and she gave R1 her pain medication after the transfer. V14 said, R1 was having pain at the time she gave her the oxycodone (narcotic pain medication.) V14 said, In light of everything, in hindsight, she should have been given the oxycodone before the transfer. We do try to premedicate before an uncomfortable event. R1's February 2024 Medication Administration Record (MAR) showed V14 documented R1 was given oxycodone at 8:01 AM for pain at a 10 out of 10. The MAR showed the dose before this was given at 7:15 PM on 2/14/24. (Nearly 13 hours prior) The National Library of Medicine online article titled oxycodone (updated 8/22/22) showed the effective duration of oxycodone to be 3-6 hours. R1's Physician Communication from 2/14/24 at 10:27 PM, showed Resident is in extreme pain rating 10/10 (10 out of 10). Within 1.5 hours of med administration, she is requesting more medication. Can this dose be increased? Any movement or repositioning seems to obviously aggravate her leg. She also has immobilizer on at this time. Please advise. The facility's Pain Management policy (revised 3/2017) showed, It is the policy of this facility to provide skilled assessment and appropriate treatment of the resident experiencing pain .the licensed nurse will administer medications and treatments as prescribed by the physician providing safe and effective pain relief .

Based on interview and record review the facility failed to notify a resident's (R1) Power of Attorney (V3) of an incident with a wheelchair and the subsequent X-ray order. This applies to 1 of 3 residents (R1) reviewed for notification in the sample of 3. The findings include: R1's Admission Record (Face Sheet) showed an original admitted [DATE] with diagnoses to include: cervical vertebra fracture (bones in the neck, was her admitting diagnosis), osteoporosis (decreased bone strength) without current pathological fracture (no fractures due to her osteoporosis), arthritis, cognitive communication deficit, lack of coordination, difficulty in walking, lack of coordination, need for assistance with personal care, and adult failure to thrive. The facility's final incident report submitted on 2/14/24 showed .it appears that [R1] moved her foot from the foot pedal while being assisted from the dining room causing her foot to touch the floor. The staff member stopped immediately when this happened and called the nurse stat. The report showed an x-ray was ordered and she sustained a nondisplaced, periprosthetic distal femoral fracture (fracture of the thigh bone near the knee and around her knee replacement hardware). R1's Progress Notes showed a communication was sent to V15 (R1's Physician) on 2/13/24 at 9:53 PM stating, Resident had incident today after dinner where she had bumped her left knee [was later corrected to right knee] causing severe discomfort and affected mobility. She stated she had a knee replacement in this knee and reported pain at 10/10 (10 out of 10). She continues to report pain and thinks her knee was twisted during incident with her wheelchair. She is requesting x-ray to left knee to rule out fracture. R1's Progress Notes showed V15 responded on 2/13/24 at 10:37 PM, Okay for Xray. R1's Progress Notes showed communication to V15 on 2/14/24 at 9:52 AM, POA was made aware of x-ray [at] care plan conference. (Nearly 12 hours after the x-ray order request.) On 2/22/24 at 10:12 AM, V3 (R1's Power of Attorney/Son) stated he was not notified of the incident until the care plan meeting on 2/14/24. V3 stated he was told R1 bumped her knee. V3 stated, he should have been notified of the incident and the X-ray request the evening it happened. On 2/22/24 at 9:44 AM, V14 (Registered Nurse/Minimum Data Set Nurse) stated she attended R1's care plan meeting on 2/14/24. V14 said, in regard to the care plan conference on 2/14/24, To my knowledge, that was the first time they were made aware of the X-ray. On 2/27/24 at 10:58 AM, V2 (Director of Nursing) stated R1's family should have been notified of the incident and X-ray order the evening of 2/13/24. V2 said it's important to notify families so they know what's going on and they can make informed decisions. The facility's Notification of Changes policy (Revision 11/2023) showed, The facility will inform the resident; consult with the resident's physician; and notify, consistent with their authority, the resident's representative when there is: (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) a significant change in the resident's physical, mental, or psychosocial status that is a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications .

Based on interview and record review the facility failed to enter an order with the facility's imaging service for several hours after an incident involving a wheelchair transportation. This applies to 1 of 3 residents (R1) reviewed for imaging in the sample of 3. The findings include: R1's Admission Record (Face Sheet) showed an original admitted [DATE] with diagnoses to include: cervical vertebra fracture (bones in the neck, was her admitting diagnosis), osteoporosis (decreased bone strength) without current pathological fracture (no fractures due to her osteoporosis), arthritis, cognitive communication deficit, lack of coordination, difficulty in walking, lack of coordination, need for assistance with personal care, and adult failure to thrive. The facility's final incident report submitted on 2/14/24 showed .it appears that [R1] moved her foot from the foot pedal while being assisted from the dining room causing her foot to touch the floor. The staff member stopped immediately when this happened and called the nurse stat. The report showed an x-ray was ordered and she sustained a nondisplaced, periprosthetic distal femoral fracture (fracture of the thigh bone near the knee and around her knee replacement hardware). R1's Progress Notes showed a communication was sent to V15 (R1's Physician) on 2/13/24 at 9:53 PM stating, Resident had incident today after dinner where she had bumped her left knee [was later corrected to right knee] causing severe discomfort and affected mobility. She stated she had a knee replacement in this knee and reported pain at 10/10 (10 out of 10). She continues to report pain and thinks her knee was twisted during incident with her wheelchair. She is requesting x-ray to left knee to rule out fracture. R1's Progress Notes showed V15 responded on 2/13/24 at 10:37 PM, Okay for Xray. R1's Progress Notes showed V12 (Assistant Director of Nursing/ADON) responded on 2/14/24 at 8:58 AM, Xray ordered stat . (More than 10 hours after V15 ordered the X-Ray) On 2/23/24 at 10:12 AM, V19 (Registered Nurse) stated she was R1's nurse the night from 6:00 PM to 6:00 AM, the night of 2/13/24. V19 stated she was not notified by the off-going nurse that an incident had occurred with R1 and that X-ray orders had been requested. V19 stated she does not recall if X-ray orders came in the evening of 2/13/24; however, V19 stated she is aware of the process for entering X-ray orders. V19 stated she checks for orders from physicians two to three times a night. On 2/22/24 at 2:30 PM, V12 (ADON) said she was made aware of the order for an X-ray by V1 (Administrator). V12 said no one submitted the order to the x-ray company prior to her sending it on 2/14/24 at 9:00 AM. On 2/27/24 at 10:58 AM, V2 (Director of Nursing) stated, Most of them check for messages three or four times a day. The X-ray should have been ordered to the X-ray company prior to 9:00 AM . V2 said entering X-ray orders timely is important so we are aware of what's going on. Entering the order quickly facilitates prompt treatment and so we know what is going on with the resident. On 2/28/24 at 7:50 AM, V1 stated, via email, the facility does not have a physician order policy. On 2/28/24 at 11:33 AM, V1 stated, via email, the facility does not have an imaging policy.

Based on interview and record review, the facility failed to identify, assess, and monitor a resident (R1) with significant respiratory changes. This failure resulted in R1 being hospitalized with acute respiratory failure, septic shock related to urinary tract infection and pneumonia, and suspected hypoxic brain injury. R1 expired in the hospital as a result of his illnesses. This failure applies to 1 of 3 residents reviewed for oxygen therapy in the sample of 6. The findings include: The Immediate Jeopardy began on [DATE] when R1 was struggling to breathe and placed on oxygen. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 10:15AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R1's electronic face sheet printed on [DATE] showed R1 had diagnoses including but not limited to type 2 diabetes, hypertension, and white matter disease. R1's facility assessment dated [DATE] showed R1 had moderate cognitive impairment, did not use oxygen, and had no pulmonary conditions. R1's physician's orders for [DATE] showed no orders for R1 to receive oxygen. R1's internal facility communication notes for [DATE] showed, [DATE] 1:50PM We did start oxygen on him at 2 liters per minute because we can't get a pulse oximetry on him, and he looks like he is struggling to breathe. (R1's physician did not respond to the above messages until [DATE] at 6:33PM- over 24 hours after the initial change in respiratory status was noted). R1's electronic medical records showed no assessment of R1's respiratory status to include lung sounds, respiratory effort, signs of dyspnea, or response to oxygen therapy. R1's last obtained pulse oximetry level and respiratory rate occurred on [DATE] at 1:15AM. (Approximately 12 hours prior to R1 being sent to the hospital). R1's neurological flow sheet dated [DATE] at 6:00AM showed, Pulse oximetry-unable to get. R1's nursing progress notes for [DATE] showed, [DATE] at 2:13AM showed, Resident lethargic all night, skin pale, grey, blood pressure ,d+[DATE], pulse 68, respirations 16, temperature 96.7 and pulse oximetry 91% on 2 liters of oxygen. R1's emergency medical services (EMS) report dated [DATE] at 1:33PM showed, Dispatched to (facility) for a male resident who is unresponsive. When arrived, patient was found lying in his bed, unresponsive to both painful and verbal stimuli .patient is on 3 liters of oxygen via nasal cannula .staff stated they are unable to obtain any blood pressure readings .skin was pale, cool, and clammy. Lung sounds were diminished. Respirations were ,d+[DATE]/minute and shallow. EMS placed patient onto 6 liters of oxygen, showing 100% oxygenation .pupils were non-reactive. En-route, EMS warmed patient with no changes noted in condition during transport to (local hospital). R1's local hospital emergency room physician note dated [DATE] showed, .Male from local nursing home unresponsive, hypotensive, flaccid with poor oxygenation. Patient was noted yesterday to be unresponsive and brought in today from paramedics .on 6 liters of oxygen with oxygen saturation 97%, blood pressure ,d+[DATE] .patient placed on Bi pap .impression and plan: pneumonia, acute urinary tract infection, hypovolemic shock .condition: critical. R1's critical care physician's note dated [DATE] showed, In the emergency room evaluation he is afebrile. Pulse and respirations are now normal. He is in acute hypoxic respiratory failure-on 6 liters oxygen. R1's internal facility communication notes for [DATE] showed, [DATE] 9:45AM Update from (local hospital); wanted information prior to emergency room visit. Resident is losing his neurological reflexes. 100% being managed with Bi pap (bi-level positive airway pressure). Critical carbon dioxide levels and all labs abnormal XXX[DATE] 2:43PM (R1) has passed away in the hospital. R1's hospital discharge summary dated [DATE] showed, Patient was admitted with unresponsiveness, diagnosed with septic shock due to urinary tract infection and pneumonia. Patient also has acute hypoxic respiratory failure, acute kidney injury, and hypernatremia .patient was unresponsive for about 48 hours .family opted for comfort measures. Patient expired. On [DATE] at 11:29AM, V5 (Licensed Practical Nurse/LPN) stated, I remember on Saturday ([DATE]), we had to put oxygen on (R1) because his breathing looked like he was struggling. I couldn't get an oxygen saturation level on him. I'm sure I assessed his lung sounds but I don't remember what they sounded like. I guess if you can't see them in his chart then I didn't document them. I remember sending a secure message through our internal communication system to the physician but now I don't recall him ever getting back to me. I didn't call any other physician in regard to (R1's) status. When we place a resident on oxygen, we should be doing a full respiratory assessment to include lung sounds, ease of breathing, and their response to the oxygen. We also have to notify the physician, which I did, he just didn't get back to me. On [DATE] at 2:02PM, V12 (R1's physician) stated, I was notified of (R1's) change in condition on [DATE]. I was not on call over the weekend so the nurse should have called the on-call number. I never work on the weekends so I'm not sure why they even sent me the message. Had the nurse notified the on-call physician as soon as she noticed respiratory changes, we could have ordered labs, imaging, or even sent him to the local emergency room with this significant of a decline. There's no reason why the nurse couldn't have reached out to another physician when I wasn't responding to her messages. Perhaps there could have been a different outcome for this resident if she had followed the proper protocol. I can't confirm that, but we all know early intervention is the best way to achieve a positive outcome. On [DATE] at 2:17PM, V2 (Director of Nursing) stated, I would expect the nurse to call the on-call physician for any skin color changes, respiratory changes, implementation of oxygen, low blood pressure. Any deviation from the resident's baseline should be reported to the physician and all the nurses know that. All the nurses also know that they are to call the on-call physician number for (V12) because he doesn't take calls on the weekends. I can't say for sure that the nurse not calling the physician contributed to his decline in condition but there definitely could have been some interventions implemented sooner had she followed the on-call protocol. On [DATE] at 10:15AM, V2 stated, I would expect the nurse to do a respiratory assessment on any resident newly placed on oxygen or having a change in condition. A pulse oximetry does not give enough detail into a resident's respiratory status or tell you lung sounds. This was an unfortunate situation, and I would expect more from my nurses. On [DATE] at 12:51PM, V5 (LPN) stated, A respiratory assessment should be completed to get a baseline of the resident's respiratory status when they are placed on oxygen so that we can continue reassessing and notify the physician of any changes. Residents that are currently on oxygen get their pulse oximetry reading checked every shift, but we don't do any other respiratory assessment on them if they are stable. If we are unable to get a pulse oximetry reading, we would try to warm the resident's hands, take off nail polish and if I still couldn't get a reading, I would notify the physician. The facility's undated policy titled, Oxygen showed, There must be a physician's order for oxygen use which includes the route and liter flow or specific oxygen concentration, and how long the oxygen is to be administered .1. When the nurse initiates oxygen therapy for a resident, she must: transcribe the physician's order in the resident's chart, document the event in the 24-hour report, place resident on hot rack (every shift) charting . The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the Immediacy and correct the compliance. Immediate Jeopardy Removal Plan: 1) How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents who are on oxygen are at risk for the same deficient practice. All residents who are on oxygen have been identified and are on the high risk resident list for monitoring. These residents are monitored every shift with an oxygen saturation reading that is documented on the medication administration record (MAR) and weekly respiratory assessments. 2) The measures the facility will take or systems the facility will alter to ensure the problem will be corrected and will not reoccur? Quality Assurance meeting was held on [DATE]. The (potential) tags were discussed and policies were pulled to determine what was not followed or what needed to be changed. (V12 Medical Director) reviewed the Change in Condition policy in which he added under vital signs systolic BP <90, resting pulse: >120 <50, pulse oximetry: <90% and pulse: >120 to be notified immediately. Also reviewed was the Oxygen policy in which a section was added under Procedure when initiating oxygen to perform and document a full respiratory assessment including oxygen saturation, lung sounds, respiratory rate, depth, and effort. Assessment will continue at least weekly. (V2 Director of Nursing) and (V3 Assistant Director of Nursing) will be providing education to all nurses on oxygen policy and procedure, Hot Rack policy, and Change in Condition policy. Education will be completed for the nurses prior to their next shift in person and/or over the phone. All nurses will be educated by [DATE]. Certified Nursing Assistants will be educated by the [DATE]. 3) Quality Assurance plans to monitor facility compliance to make sure that corrections are achieved and permanent. (V2) and/or (V3) will monitor the 24-hour reports, the Stop and Watch reports, and high priority notes on electronic medical record system to assure policies are being followed. Audits will continue for 2x/week for 3 months and ongoing as needed. Will provide any further education as needed and address at Quality Assurance meetings. On [DATE] at 4:00PM, a review of the facility's in-service record showed all staff working the remainder of the day on [DATE] were in-serviced on change in condition policy, oxygen policy, hot rack charting, procedure for initiating oxygen and respiratory assessments. As of this time, 55% of the nurses had received the in-service training with the remainder of the staff receiving the education prior to the start of their next shift.

Based on interview and record review, the facility failed to notify a resident's physician of a change in condition for greater than 24 hours. This failure resulted in a decline in R1's condition leading to hospitalization for acute hypoxic respiratory failure, sepsis, and suspected hypoxic brain injury. This applies to 1 (R1) of 3 residents reviewed for change in condition in the sample of 6. The findings include: The Immediate Jeopardy began on 11/4/23 when R1 began experiencing increased incontinence, assistance with transfers, assistance with feeding. V1 (Administrator) was notified of the Immediate Jeopardy on 11/14/23 at 10:15AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 11/14/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R1's electronic face sheet printed on 11/8/23 showed R1 had diagnoses including but not limited to type 2 diabetes, hypertension, and white matter disease. R1's facility assessment dated [DATE] showed R1 had moderate cognitive impairment, required set up help with transfers, ambulation, and eating, and did not use oxygen. R1's physician's orders for November 2023 showed no orders for R1 to receive oxygen. R1's nursing progress notes dated 11/4/23 at 12:35PM showed, Resident has been incontinent all night, refuses to get up to bathroom. Resident refusing to sit up so he can eat breakfast. Assisted with 2 to finish getting him up and to his recliner. Medications given. On his light every 5 min or so asking for different things shower, hip hurts, spa bath, etc. Medications taken and resident is in his wheelchair for lunch so he can get out of his room safely. 11/5/23 2:13am Resident lethargic all night, skin pale, grey, Blood pressure 105/ 62, pulse 68, respirations 16, temperature 96.7, pulse oximetry 91% on 2L oxygen via nasal cannula. 11/5/23 1:24PM physician notified of blood glucose of 577. On call physician notified and gave orders to send to emergency room for evaluation. (No physician notification was made regarding R1's condition change from 11/4/23 at 12:35PM until 11/5/23 at 1:24PM). R1's internal facility communication notes dated 11/4/23 showed, Called power of attorney and informed her of his condition today. She said just let her know if things change. She stated that she knows he is depressed and wants to leave here but she knows it is not going to happen. We did start oxygen on him at 2L/minute because we can't get a pulse oximetry on him and looks like he is struggling to breathe .evening medications were crushed and put in pudding, and he did take them. Refused the (nutritional) drink. Would not drink from the straw and did not swallow from a glass. (R1's physician did not acknowledge the communication regarding R1 until 11/5/23 at 6:33PM after R1 had already been sent to the hospital). R1's emergency medical services (EMS) report dated 11/5/23 at 1:33PM showed, Dispatched to (facility) for a male resident who is unresponsive. When arrived, patient was found lying in his bed, unresponsive to both painful and verbal stimuli. Staff stated patient has been declining in condition for about a week and has been unresponsive for the past 2 days .patient is on 3 liters of oxygen via nasal cannula .staff stated they are unable to obtain any blood pressure readings .skin was pale, cool, and clammy. Lung sounds were diminished. Respirations were 10-12/minute and shallow. EMS placed patient onto 6 liters of oxygen, showing 100% oxygenation .pupils were non-reactive. En-route, EMS warmed patient with no changes noted in condition during transport to (local hospital). R1's local hospital emergency room physician note dated 11/5/23 showed, .Male from local nursing home unresponsive, hypotensive, flaccid with poor oxygenation. Patient was noted yesterday to be unresponsive and brought in today from paramedics .on 6 liters of oxygen with oxygen saturation 97%, blood pressure 60/30 .patient placed on Bi pap .impression and plan: pneumonia, acute urinary tract infection, hypovolemic shock .condition: critical. R1's critical care physician's note dated 11/6/23 showed, In the emergency room evaluation he is afebrile. Pulse and respirations are now normal. He is in acute hypoxic respiratory failure-on 6 liters oxygen. On 11/8/23 at 1:44PM, V10 (Certified Nursing Assistant/CNA) stated, I worked with (R1) on Friday night (11/3/23) and I remember he was incontinent which was unusual for him. He was normally pretty independent and just need cues and reminders. He ambulated independently with a walker and took himself to the bathroom. When I came back on Saturday (11/4/23), the report I got was that (R1) was actively dying and was to receive comfort care measures. I remember trying to give him a shake for dinner and he couldn't even drink it out of the straw. In my opinion his change in condition started on Friday because I specifically remember it being the day, he got an x-ray. (R1 did receive an x-ray of his hip on 11/3/23). On 11/8/23 at 2:28PM, V11 (Restorative CNA) stated, Saturday morning (11/4/23) I went into (R1's) room to get him up for the day and he said his hip hurt. I told the nurse, and she gave him Tylenol. I stood him up to get him ready to transfer and he wanted to lay back down so I helped him reposition in bed. I came back around 10am I went back to get him up for lunch and he was unstable with the transfer, so I used a wheelchair to take him to the dining room and he was fed at the assisted table. Usually, he is independent, but something seemed off about him that day. Staff in the dining room told me he refused lunch, so I took him back to his room to lay him down and he was starting to drool and couldn't stand. I asked another CNA to help me transfer him and then I told the nurse (V5 Licensed Practical Nurse/LPN) that I wasn't able to obtain any vitals on him, so she came in and put oxygen on him and checked on him. I don't know what else she did because I left the room after that. On 11/8/23 at 11:29AM, V5 (LPN) stated, I remember on Saturday (11/5/23), we had to put oxygen on (R1) because his breathing looked like he was struggling. I couldn't get an oxygen saturation level on him. I'm sure I assessed his lung sounds but I don't remember what they sounded like. I guess if you can't see them in his chart then I didn't document them. I remember sending a secure message through our internal communication system to the physician but now I don't recall him ever getting back to me. I didn't call any other physician regarding (R1's) status. When we place a resident on oxygen, we should be doing a full respiratory assessment to include lung sounds, ease of breathing, and their response to the oxygen. We also have to notify the physician, which I did, he just didn't get back to me. It's hard to believe that (R1) passed away so quickly. He was completely fine on Friday (11/4/23). We should notify a resident's physician of any condition change noted, so basically it's anything abnormal for them we should be letting the physician know. On 11/8/23 at 2:02PM, V12 (R1's physician) stated, I was notified of (R1's) change in condition on 11/5/23. I was not on call over the weekend so the nurse should have called the on-call number. I never work on the weekends so I'm not sure why they even sent me the message. The nurses are responsible for notifying a resident's physician if the resident is experiencing any change in condition such as increased incontinence, lethargy, oxygen implementation, skin color changes, etc. Had the nurse notified the on-call physician as soon as she noticed respiratory changes, we could have ordered labs, imaging, or even sent him to the local emergency room with this significant of a decline. There's no reason why the nurse couldn't have reached out to another physician when I wasn't responding to her messages. Perhaps there could have been a different outcome for this resident if she had followed the proper protocol. I can't confirm that, but we all know early intervention is the best way to achieve a positive outcome. On 11/8/23 at 2:17PM, V2 (Director of Nursing) stated, I would expect the nurse to call the on-call physician for any skin color changes, respiratory changes, implementation of oxygen, low blood pressure. Any deviation from the resident's baseline should be reported to the physician and all the nurses know that. All the nurses also know that they are to call the on-call physician number for (V12) because he doesn't take calls on the weekends. I can't say for sure that the nurse not calling the physician contributed to his decline in condition but there definitely could have been some interventions implemented sooner had she followed the on-call protocol. The facility's policy titled, Notification of Changes dated 10/19 showed, The facility will inform the resident; consult with the resident's physician; and notify, consistent with their authority, the resident's representative when there is: (B) A significant change in the resident's physical, mental, or psychosocial status that is a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications. (C) A need to alter treatment significantly that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment. The Immediate Jeopardy that began on 11/4/23 was removed on 11/14/23 when the facility took the following actions to remove the Immediacy and correct the compliance. Immediate Jeopardy Removal Plan: 1) How will the facility identify other residents having the potential to be affected by the same deficient practice? All residents who experience a significant change of status/decline in condition from their baseline. 2) The measures the facility will take or systems the facility will alter to ensure the problem will be corrected and will not reoccur? Quality Assurance meeting was held on November 9, 2023. The (potential) tags were discussed, and policies were pulled to determine what was not followed or what needed to be changed. (V12 Medical Director) reviewed the Change in Condition policy in which he updated lab values on NA(Sodium), PT/INR (Protime/International Normalized Ratio), Blood glucose >400 or <60 and under vital signs systolic blood pressure <90, resting pulse: >120 <50, pulse oximetry: <90% and pulse >120 to be notified immediately. (V2 Director of Nursing) and/or (V3 Assistant Director of Nursing) will be providing education to all the nursing staff on reporting a decline in resident's condition to nurse's and physician. All nurses will also be educated on the on-call physician protocol and the Hot Rack policy. Education will be completed for the nurses prior to the next shift in person and/or over the phone. Nurses will be educated by 11/15/23. Certified nursing assistants will be educated by 11/16/23. 3) Quality Assurance plans to monitor facility compliance to make sure that corrections are achieved and permanent. (V2) and/or (V3) will monitor the 24-hour reports, the Stop and Watch reports, and high priority notes on electronic medical record system to ensure policies are being followed. Audits will continue for 2x/week for 3 months and ongoing as needed. Will provide any further education as needed and address at Quality Assurance. On 11/14/23 at 4:00PM, a review of the facility's in-service record showed all staff working the remainder of the day on 11/14/23 were in-serviced on change in condition policy, on-call physician protocol, decline in condition reporting, and hot rack charting. As of this time, 55% of the nurses had received the in-service training with the remainder of the staff receiving the education prior to the start of their next shift.

Based on observation, interview, and record review the facility failed to ensure a pressure ulcer was identified prior to becoming a stage 3 and failed to ensure treatment orders were in place upon discovery of the pressure injury. This applies to 1 of 3 residents (R67) reviewed for pressure wounds in the sample of 20. This failure resulted in R67's pressure ulcer declining from a stage 3 to unstageable. The findings include: R67's Face Sheet shows her diagnoses to include type 2 diabetes mellitus, obesity, atrial fibrillation, depression, irritant contact dermatitis, and seborrheic dermatitis. The same document shows R67's admitted was 11/9/22. On 2/16/23 at 10:50 AM, R67 was sitting in her recliner with the leg rest down. A dressing to the right ankle and the left calf was visible. R67 said, she likes to stay in her recliner, and will put a pillow under her calves when the leg rest is up. R67 said they do the dressing at night and doesn't care to have it done during the day. The 12/16/22 Weekly Pressure Injury Record shows a stage 3 Pressure Ulcer to the back of R67's left calf, measuring 2.0 x 1.0 x 0.1cm (centimeters). The same document shows the wound bed is 100% slough (dead tissue). The onset date of the wound is documented as 12/16/22. R67's December/2022 TAR (Treatment Administration Record) does not show any dressing change orders for the stage 3 pressure wound to the left calf. R67's January/2023 TAR does not show any dressing change orders for the stage 3 pressure wound to the left calf until 1/24/23, 38 days after the onset of the stage 3 pressure ulcer discovery. The 1/23/23 Weekly Pressure Injury Record shows the pressure wound to the left calf declined to 4.0 x 4.0 x UTD (Unable to Determine Depth). The wound would now be classified as an unstageable pressure ulcer with the wound bed 100% covered by slough. On 2/28/23 at 11:35 AM, V2 (Director of Nursing/DON) said, she looked and can't find where treatment was being done on R67's stage 3 pressure wound to her left calf between the onset date of 12/16/22 and 1/24/23 when the Physician ordered the dressing change. V2 said, her expectation is that when a wound is discovered the floor Nurse, and the Wound Nurse are notified. V2 said the Physician should be notified so orders can start as soon as possible to start the healing process, otherwise the wound could get worse. V2 said that order should be placed on the TAR so the Floor Nurse knows the dressing change needs to be done, otherwise the treatment won't get done, and the wound could get worse. V2 said she doesn't know why the delay in treatment happened. V2 said, V3 (Wound care Coordinator) is out of the Country. V2 said, the Floor Nurse does the dressing change based on the TAR day to day. On 2/28/23 at 12:22 PM, V2 said, the facility has a Certified Wound Nurse that comes in 1x a month and V3 rounds with her. V2 said the Certified Wound Nurse was due to come in on 12/18/22 but didn't because she was on a leave of absence. V2 said, all wounds should be found before a stage 3 pressure ulcer. On 2/28/23 at 11:52 AM, V7 (Registered Nurse/RN) said, she knows if a dressing change needs to be done by looking at the TAR. V7 said, she wouldn't know otherwise. V7 said, a pressure wound should be found before a stage 3. V3 (Wound care Coordinator) was not available for interview due to being out of the Country. An attempt was made to contact the facility's Medical Director with a message left and a phone number to call, but the call was not returned. R67's shower sheets were requested for 12/14/22-12/18/22, but the facility only could find 12/8/22. R67's 12/5/22 Braden Scale for Predicting Pressure Ulcer Risk shows a score of 17, which means R67 is at a mild risk for pressure ulcers. R67's 12/29/22 Braden Scale for Predicting Pressure Ulcer Risk shows a score of 16, even after the discovery of a stage 3 pressure ulcer on her left calf. R67's Physician Order Sheet shows, on 1/24/23 the dressing change order is to the back of the left calf, cluster wound: cleanse area, apply (wound cleanser) to wound bed, cover with ABD (Abdominal Dressing), (gauze wrapping) and tape QD (every day) until resolved. R67's Progress notes make no mention of a pressure ulcer discovery on 12/16/22. The undated Pressure Ulcer Prevention Program shows the facility will ensure that a resident that enters the facility without a pressure sore does not develop pressure sores .The facility will promote the healing of pressure ulcers that are present .and the facility will prevent the development of additional pressure ulcers. The Wound care Coordinator's responsibility is to confer with the residents attending Physician regarding treatment recommendations made by the Wound Care Nurse; documents and transcribes all new Physician orders received.

Based on interview and record review the facility failed to immediately notify the physician of a significant change in condition when R64's oxygen saturation was 81 percent on room air and became unresponsive. These failures resulted in R64 becoming unresponsive, restless, and hypoxic for over 14 hours before being sent to the hospital for medical treatment. This applies to 1 resident (R64) outside of the sample reviewed for physician notification. The findings include: R64's Face sheet dated August 17, 2017, shows R64 was admitted on [DATE] with [DIAGNOSES REDACTED]. R64's State of Illinois Do Not Resuscitate (DNR)/ Practitioner Orders for Life-Sustaining Treatment (POLST) Form dated October 14, 2015, showed R64 chose to have selective treatment of [REDACTED]. R64 did not want to be intubated but may consider less invasive mechanical airway support. R64 was to be transferred to hospital if indicated. physician progress notes [REDACTED]. Under the exam section of the progress note, R64 was in no acute distress, his lungs were clear to auscultation, his heart had a regular rate and rhythm and he had no [MEDICAL CONDITION] in his extremities. R64's Physician Orders for November 2017, shows R64's physician orders to include: DNR-Selective treatment; For respiratory distress check oxygen saturation. If less than 90 percent, start oxygen at 2 liters per nasal cannula. Listen to lung sounds and get a full set of vital signs; Notify the provider for further orders; May use physician standing orders. A physician order dated April 4, 2016, showed an order for [REDACTED]. There is no physician order for [REDACTED]. The facility's Daily Assignment Sheet Vital Sheet dated November 10, 2017 showed R64's blood pressure was 148/80, oxygen saturation of 81 percent (There was no time indicated on the vital sheet.) R64's Nurses Notes dated Friday, November 10, 2017 at 5:42 PM, showed, R64 was sitting in his wheelchair at the nurses station right before supper and he was noticed a grayish color with his head back. The other nurse could not feel a pulse and then he turned red in color and I was walking over to him and he let out a big sigh. R64 was not responding and he was put to bed where he still remains comfortable. Left message for POA to call back to give her an update of his condition. Blood pressure just an hour before was 148/80. The next entry in the nurses notes was on Saturday November 11, 2017 at 10:30 AM (over 14 hours later), R64 presents with an oxygen saturation of 72 percent on room air, gray dusky appearance and non responsive with restlessness. R64's Power of Attorney notified and insistent on transport to the emergency room . R64 transported to local emergency room for evaluation. Temperature 97.6 degrees Fahrenheit, pulse of 68, respirations of 24 and oxygen saturation of 72 percent. Unable to obtain a blood pressure due to restlessness. The last obtained blood pressure on the night shift was 154/68. Physician notified of events. The facility's electronic communication system showed an electronic communication was sent to recipients including; V1 (Administrator), V2 (Director of Nursing) and V3 (Physician) on Friday, November 10, 2017 at 5:42 PM. The communication showed, R64 was sitting in his wheelchair at the nurses station right before supper and he was noticed a grayish color with his head back. The other nurse could not feel a pulse and then he turned red in color and I was walking over to him and he let out a big sigh. R64 was not responding and he was put to bed where he still remains comfortable. Left message for POA to call back to give her an update of his condition. Blood pressure just an hour before was 148/80. The next electronic communication sent was on Saturday November 11, 2017 at 10:08 AM, Doctor, R64 presents with an oxygen saturation of 72 percent. Oxygen was applied at 2 liters per minute per nasal cannula raising saturation level to 75 percent. The oxygen was increased to 3 liters per minute with an oxygen saturation of 79 percent with a recheck and the oxygen saturation level down to 73percent. The POA was notified and insistent on transport to emergency room for evaluation. We are doing so at this time . R64 is restless and we are unable to obtain a blood pressure. (R64) color remains gray and dusky. Is transport okay? At 11:54, V2 (Director of Nursing) responded, We have a standing order to transport to the emergency room if the POA wishes. We can write the order. The physician did not respond to the electronic communication until Sunday November 12, 2017 at 11:54 AM, Noted. On January 12, 2018 at 2:00 PM, V5 (Certified Nursing Assistant-CNA) stated she was working November 10, 2017 the day of R64's incident. Around 4:30 PM, V4 (Licensed Practical Nurse) asked her to put R64 to bed because he was pale and had an episode V5 put R64 to bed with another aide. V5 did not recall which aide assisted her with the transfer. I can't say he was fine. He was really bad not acting himself, really pale and pretty much unconscious; liked passed out. V5 said she took R64's vital signs and wrote them down on a piece of paper and gave the paper to the nurse. On January 12, 2018 at 2:17 PM, V6 (CNA) said she was working the night shift of November 10th into the 11th, 2017. V6 stated she remembered R64 moaning and groaning and having hallucinations. R64 was having some mottling on his legs. V6 stated she reported the moaning and mottling to her nurse. V6 said her nurse stated she was aware of the moaning and mottling. On January 12, 2018 at 12:52 PM, V7 (LPN) stated she did not recall the night of November 10-11, 2017. V7 confirmed the blood pressure recorded on the medication administration record on November 11 was her writing. V7 stated the twenty four hour report sheet should have the rest of R64's vital signs for the night shift. V7 stated she should have recorded a note for R64 because he was on the hot rack for change in condition. V7 stated she did not call the physician or POA that night shift. V7 stated residents with oxygen saturations of less than 90 percent should have oxygen placed and the physician should be called. The facility's twenty four hour report sheet dated November 10, 2017, showed R64 was on the hot rack charting. There is a notation under the days and evening shift column of,daily blood pressures for one week. (R64) had a spell went gray, leaned back in wheelchair, turned red and took a big sigh, we put him to bed. Under the night shift there was a notation for R64 of Not doing well. On January 12, 2018 at 9:47 AM, V4 (Licensed practical Nurse) stated she did not recall the incident of November 11, 2017 with R64. V4 stated the physician is notified via electronic communication system for changes with a resident with the exception of emergencies then the physician is called. V4 stated emergences would include shortness of breath, episodes of unresponsiveness, residents not having a pulse or residents that are difficult to arouse. V4 stated if a resident is gray in color and unresponsive the staff is to call the doctor. V4 stated if the resident is gray or ashen she would start oxygen and notify the physician and POA. V4 stated she does not remember starting oxygen or calling the physician. If she had she would have documented in the nurses notes. V4 stated it was important to notify the physician of a change in condition because they are trying to save a life. It would never be appropriate to not call the physician and if the physician was not responding the on call physician should be called. On January 12, 2018 at 12:15 PM, V8 (Assistant Director of Nursing) stated she recalled the incident at the nurses desk when R64 turned gray. I can't really remember what all happened but I know he did not die that day. V8 stated vital signs should be taken and the physician should have been called. If the doctor does not respond the on call physician should be called. V8 stated she would have sent the resident out if he had an episode like that. On January 12, 2017 at 10:58 AM, V2 stated there is no evidence that the physician was notified R64's oxygen saturation was 81 percent and the staff could not feel a pulse. The doctor should have been notified. If the staff did not get a response from the physician, the on call physician should have been notified. When there is no response the resident should be sent out. V2 stated there is no evidence that oxygen was administered prior to the morning of November 11th when the day nurse started the oxygen. On January 12, 2018 at 1:25 PM, V3 stated he should have been called or the on call physician should have been called for a resident having an episode of unresponsiveness, gray and ashen in color, difficulty finding a pulse and an oxygen saturation of 81per cent on room air and restlessness. The resident was in apparent distress and needed to be evaluated. The facility's Physician Notification Summary, When to Call the Doctor policy (undated), shows when a physician needs to be notified immediately or when the physician can be faxed or logged. The physician is to be called immediately when a resident is experiencing labored breathing, ashen or dusky appearance and cyanosis. The physician is to be called immediately when the pulse oximetry recording is less than 92 percent and the pulse is less than 50 beats per minute. R64's Standing Orders dated November 9, 2017, showed, Respiratory Distress: 1. Check oxygen saturation. If less than 90 percent start oxygen at two liters per minute. Listen to lung sounds and get a full set of vital signs. Notify provide for further orders. 2. Oxygen saturation less than 90 percent on two liters/ per minute nasal cannula is not adequate to maintain saturations, then may use non- rebreather mask with 15 liters of oxygen. Notify provider and call 911. R64's Facility Patient Medical/Emergency Contact Person Form dated October 14, 2015, showed, It is the policy of the facility to immediately inform the resident: consult with the resident physician and if known the resident's legal representative or an interested family member when there is: .b) a significant change in the resident's physical, mental or psychosocial status (i.e. a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical compromise.) .

Based on interview and record review the facility neglected to follow its physician notification policies by failing to immediately call the physican when R64 had a significant change in condition. The facility neglected to follow its physician standing orders for a resident experiencing respiratory distress. These failures resulted in R64 having episode of unresponsiveness, restless, and hypoxic for over 14 hours before being assessed and sent out for medical treatment. This applies to 1 resident (R64) outside of the sample reviewed for neglect. The findings include: The facility's undated physician Notification Summary, When to Call the Doctor, showed to immediately call the physican when a resident has a sudden onset of change in mental status, ashen or dusky appearance with cyanosis, pulse oximetry less than 92 percent and a pulse less than 50 (beats per minute). The facility's standing orders for R64 dated November 9, 2017, showed for a resident in respiratory distress: 1. Check oxygen saturation. If less than 90 percent, start oxygen at two liters per nasal cannula. Listen to lung sounds and get a full set of vital signs. Notify provider for further orders. 2. Oxygen saturation less than 90 percent and 2 liters nasal cannula is not adequate to maintain saturations, then may use a non rebreather mask with 15 liters of oxygen. Notify provider and call 911. The facility's Patient Medical/Emergency Contact Person form dated October 14, 2015, showed It is the policy of the facility to immediately inform the resident;consult with the resident physician; and if known, notify the resident's legal representative or an interested family member when there is: .b) a significant change in the resident's physical, mental, or psychosocial status (i.e. a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications.) . R64's Nurses Notes dated November 10, 2017 at 5:42 PM, showed, R64 was sitting in his wheelchair at the nurses' station right before supper and he was noticed a grayish color with his head back. The other nurse could not feel a pulse and then he turned red in color and I was walking over to him and he let out a big sigh. R64 was not responding and he was put to bed where he still remains comfortable. Left message for POA to call back to give her an update of his condition. Blood pressure just an hour before was 148/80. The facility's Daily Assignment Sheet Vital Sheet dated November 10, 2017 showed R64's blood pressure was 148/80,and his oxygen saturation was 81 percent (There was no time indicated on the vital sheet.) R64's Nurses Note dated November 11, 2017 at 10:30 AM, showed R64 presents with an oxygen saturation of 72 percent on room air, gray and dusky appearance and non responsive with restlessness. POA notified and insistent on transport to the emergency room . R64 transported to local emergency room for evaluation. R64's vital signs were a temperature of 97.6 degrees Fahrenheit, pulse of 68, and respiration of 24. Unable to obtain a blood pressure due to restlessness. R64's last blood pressure obtained was on the night shift 154/68. The physician was notified. The facility's electronic communication system showed an electronic communication was sent to recipients including; V1 (Administrator), V2 (Director of Nursing) and V3 (Physician) on Friday, November 10, 2017 at 5:42 PM. The communication showed, R64 was sitting in his wheelchair at the nurses station right before supper and he was noticed a grayish color with his head back. The other nurse could not feel a pulse and then he turned red in color and I was walking over to him and he let out a big sigh. R64 was not responding and he was put to bed where he still remains comfortable. Left message for POA to call back to give her an update of his condition. Blood pressure just an hour before was 148/80. The next electronic communication sent was on Saturday November 11, 2017 at 10:08 AM, Doctor, R64 presents with an oxygen saturation of 72 percent. Oxygen was applied at 2 liters per minute per nasal cannula raising saturation level to 75 percent. The oxygen was increased to 3 liters per minute with an oxygen saturation of 79 percent with a recheck and the oxygen saturation level down to 73percent. The POA was notified and insistent on transport to emergency room for evaluation. We are doing so at this time . R64 is restless and we are unable to obtain a blood pressure. (R64) color remains gray and dusky. Is transport okay? At 11:54, V2 (Director of Nursing) responded, We have a standing order to transport to the emergency room if the POA wishes. We can write the order. The physician did not respond to the electronic communication until Sunday November 12, 2017 at 11:54 AM, Noted. On January 12, 2018 at 9:47 AM, V4 (Licensed practical Nurse) stated she did not recall the incident of November 11, 2017 with R64. V4 stated the physician is notified via electronic communication system for changes with a resident with the exception of emergencies then the physician is called. V4 stated emergences would include shortness of breath, episodes of unresponsiveness, residents not having a pulse or residents that are difficult to arouse. V4 stated if a resident is gray in color and unresponsive the staff is to call the doctor. V4 stated if the resident is gray or ashen she would start oxygen and notify the physician and POA. V4 stated she does not remember starting oxygen or calling the physician. If she had she would have documented in the nurses notes. V4 stated it was important to notify the physician of a change in condition because they are trying to save a life. It would never be appropriate to not call the physician and if the physician was not responding the on call physician should be called. On January 12, 2018 at 12:15 PM, V8 (Assistant Director of Nursing) stated she recalled the incident at the nurses desk when R64 turned gray. She stated she may have checked for a pulse, but he came back. We (facility staff) might have taken him to his room. I can't really remember what all happened but I know he did not die that day. V8 stated vital signs should have been taken and the physician should have been called. If the doctor does not respond the on call physician should be called. V8 stated she would have sent the resident out if he had an episode like that. On January 12, 2017 at 10:58 AM, V2(Director of Nursing) stated there is no evidence that the physician was notified R64's oxygen saturation was 81 percent and the staff could not feel a pulse. The doctor should have been notified. If the staff did not get a response from the physician, the on call physician should have been notified. When there is no response the resident should be sent out. V2 stated there is no evidence that oxygen was administered prior to the morning of November 11th when the day nurse started the oxygen. On January 12, 2018 at 1:25 PM, V3 (Physician) stated he should have been called or the on call physician should have been called for a resident having an episode of unresponsiveness, gray and ashen in color, difficulty finding a pulse and an oxygen saturation of 81per cent on room air and restlessness. The resident was in apparent distress and needed to be evaluated. On January 17, 2018 at 9:15 AM, V10 (Corporate Nurse Consultant) stated they have no specific policies for monitoring and assessments for a change in resident condition. The nurses should follow the Nurse Practice Act.

Based on interview and record review the facility failed to monitor, assess, and intervene when a change in a resident's condition occurred. The facility failed to ensure a resident experiencing a low oxygen saturation level and change in skin color received medical treatment. These failures resulted in R64 having episodes of unresponsiveness, restless, and being hypoxic for over 14 hours before being assessed and sent out for medical treatment. This applies to 1 resident (R64) outside of the sample reviewed for change in condition. the findings include: R64's Face sheet dated August 17, 2017, shows R64 was admitted on [DATE] with [DIAGNOSES REDACTED]. R64's State of Illinois Do Not Resuscitate (DNR)/ Practitioner Orders for Life-Sustaining Treatment (POLST) Form dated October 14, 2015, showed R64 chose to have selective treatment of [REDACTED]. R64 did not want to be intubated but may consider less invasive mechanical airway support. R64 was to be transferred to hospital if indicated. R64's Physician order [REDACTED].>1. DNR-Selective treatment. For respiratory distress check oxygen saturation. If less than 90 percent, start oxygen at 2 liters per nasal cannula. Listen to lung sounds and get a full set of vital signs. Notify the provider for further orders. 2. May use physician standing orders. 3. Oxygen at 2 liters per nasal cannula while sleeping as needed with a [DIAGNOSES REDACTED]. 4. Per POA request, transport to the emergency room for evaluation dated November 11, 2017. 5. On November 9, 2017, new order to start [MEDICATION NAME][MEDICATION NAME] wean off [MEDICATION NAME] and discontinue two of R64's blood pressure medications (Imdur and [MEDICATION NAME]) and increase [MEDICATION NAME]. Blood pressures to be monitored daily for a week. The facility's Standing Orders for R64 dated November 9, 2017, shows, Respiratory distress: 1. Check oxygen saturation. If less than 90 % start oxygen at 2 liters per minute. Listen to lung sounds and get a full set of vitals. Notify provider for further orders. Hospital transfers: 1. If POA is requesting resident be transferred to hospital, transfer them. Notify provider. R64's physician progress notes [REDACTED]. Under the exam section of the progress note, R64 was in no acute distress, his lungs were clear to auscultation, his heart had a regular rate and rhythm and he had no [MEDICAL CONDITION] in his extremities. R64's Urine Dip results dated November 10, 2017 at 10:00AM, showed R64's urine was positive for [MEDICATION NAME], trace amount of protein, small amount of blood, moderate amount of [MEDICATION NAME], small amount of bilirubin and 3 plus for glucose. (These results are abnormal). The facility's electronic communication shows the results of R64's urine dip were uploaded to the (physician notification) system on Friday November 10, 2017 at 3:08 PM. On Sunday November 12, 2017 at 12:39 PM (two days later), V3 (Physician) responded, He is in the hospital now, correct? There is no documentation showing the facility contacted the physician by phone when there was no response by the physician at the end of the day on Friday, November 10, 2017. R64's Nurses Notes dated November 10, 2017 at 5:42 PM, showed, R64 was sitting in his wheelchair at the nurses' station right before supper and he was noticed a grayishcolor with his head back. The other nurse could not feel a pulse and then he turned red in color and I was walking over to him and he let out a big sigh. R64 was not responding and he was put to bed where he still remains comfortable. Left message for POA to call back to give her an update of his condition. Blood pressure just an hour before was 148/80. The facility's Daily Assignment Sheet Vital Sheet dated November 10, 2017 showed R64's blood pressure was 148/80, oxygen saturation of 81 percent (There was no time indicated on the vital sheet.) On January 12, 2018 at 9:47 AM, V4 (Licensed practical Nurse) stated she did not recall the incident of November 11, 2017 with R64. V4 stated if the resident is gray or ashen she would start oxygen and notify the physician and POA. V4 stated she does not remember starting oxygen or calling the physician. If she had she would have documented in the nurses notes. On January 12, 2018 at 2:00 PM, V5 (Certified Nursing Assistant-CNA) stated she was working November 10, 2017 the day of R64's incident. Around 4:30 PM, V4 (Licensed Practical Nurse) asked her to put R64 to bed because he was pale and had an episode V5 put R64 to bed with another aide. V5 did not recall which aide assisted her with the transfer. I can't say he was fine. He was really bad not acting himself, really pale and pretty much unconscious; liked passed out. V5 said she took R64's vital signs and wrote them down on a piece of paper and gave the paper to the nurse. On January 12, 2018 at 1:51 PM, V9 (CNA) stated she worked the afternoon of November 10, 2017. V9 stated right before supper around 4:30 PM she was asked to transfer R64 to his bed. R64 was unresponsive, gray in color and his eyes were glazed over. He wasn't there. V9 said she assisted V5 with the transfer and then left the room. On January 12, 2018 at 12:15 PM, V8 (Assistant Director of Nursing) stated she recalled the incident at the nurses desk when R64 turned gray. She stated she may have checked for a pulse, but he came back. We (facility staff) might have taken him to his room. I can't really remember what all happened but I know he did not die that day. V8 stated vital signs should be taken and the physician should have been called. If the doctor does not respond the on call physician should be called. V8 stated she would have sent the resident out if he had an episode like that. On January 12, 2018 at 2:17 PM, V6 (CNA) said she was working the night shift on November 10th into the 11th, 2017. V6 stated she remembered R64 moaning and groaning and having hallucinations. R64 was having some mottling on his legs. V6 stated she reported the moaning and mottling to her nurse. Her nurse stated she was aware of the moaning and mottling. R64's Behavior Log dated September to November 2017 was reviewed. The only behavior documented was on the night shift on November 11, 2017. R64 was moaning and groaning and having hallucinations. R64 was observed looking at the ceiling with a terrified look on his face while crying out. Intervention done was to reassure him everything was okay and a cool washcloth was applied to his forehead. The intervention did not change his behavior. On January 12, 2017 at 12:52 PM, V7 (LPN) stated she did not recall the night of November 10-11, 2017. V7 confirmed the blood pressure recorded on the medication administration record on November 11th was her writing. V7 stated the twenty four hour report sheet should have the rest of R64's vital signs for the night shift. V7 stated she should have recorded a note for R64 because he was on the hot rack for change in condition. V7 stated she did not call the physician or POA that night shift. V7 stated residents with oxygen saturations of less than 90 percent should have oxygen initiated and the physician should be called. R64's Nurses Notes were reviewed for a nurse note for the night shift on November 10-November 11, 2017. There was no night shift nurse note. R64's Medication Administration Record for November 2017, showed a blood pressure of 156/78 on November 11, 2017. There was no documentation of oxygen being administered. The facility's twenty four hour report sheet dated November 10, 2017, showed R64 was on the hot rack charting. There is a notation under the days and evening shift column of, daily blood pressures for one week. (R64) had a spell went gray, leaned back in wheelchair, turned red and took a big sigh, we put him to bed. Under the night shift there was a notation for R64 of Not doing well. There were no vital signs for R64 documented on the twenty four hour sheet. R64's Nurses Note dated November 11, 2017 at 10:30 AM, showed R64 presents with an oxygen saturation of 72 percent on room air, gray and dusky appearance and non responsive with restlessness. POA notified and insistent on transport to the emergency room . R64 transported to local emergency room for evaluation. R64's vital signs were a temperature of 97.6 degrees Fahrenheit, pulse of 68, and respiration of 24. Unable to obtain a blood pressure due to restlessness. R64's last blood pressure obtained was on the night shift 154/68. The physician was notified. R64's Nurses Note dated November 11, 2017 at 6:08 PM, showed R64 was admitted to the coronary care unit at a local hospital with [MEDICAL CONDITION] secondary to severe urinary tract infection and dehydration. R64's MDS- Minimum Data Set, dated dated dated [DATE] and November 11, 2017 showed R64 did not have hallucinations and had behaviors directed towards other and rejected care. On January 12, 2017 at 10:58 AM, V2 (Director of Nursing) stated when R64's oxygen saturation was 81 percent and the staff had difficulty finding a pulse R64 should have been sent out. Ninety nine percent of the time the nurses send the residents out. When in doubt send them out. The nurses should have started oxygen when his oxygen saturation was 81 percent and sent him out. V2 stated there is no evidence that oxygen was administered prior to the morning of November 11th when the day nurse started the oxygen. On January 12, 2018 at 1:25 PM, V3 (Physician) stated he expected facility staff to do a complete set of vitals when a resident has a pulse ox of 81 percent. If the resident is in distress the resident should have been sent out unless the resident had specific wishes for no hospitalization s. Oxygen should have been started when his oxygen level was only 81 percent. The resident was in apparent distress and needed to be evaluated. The facility's electronic communication system showed a message was sent on Friday, November 10, 2017 at 5:42 PM to recipients including V1(administrator), V2 (Director of Nursing) and V3 (Physician). The communication showed, (R64) was sitting in his wheelchair at the nurses' station right before supper and he was noticed a grayish color with his head back. The other nurse could not feel a pulse and then he turned red in color and I was walking over to him and he let out a big sigh. R64 was not responding and he was put to bed where he still remains comfortable. Left message for POA to call back to give her an update of his condition. Blood pressure just an hour before was 148/80. The next electronic communication sent was on Saturday November 11, 2017 at 10:08 AM, Doctor, R64 presents with an oxygen saturation of 72 percent. Oxygen was applied at 2 liters per minute per nasal cannula raising saturation level to 75 percent. The oxygen was increased to 3 liters per minute with an oxygen saturation of 79 percent with a recheck and the oxygen saturation level down to 73percent. The POA was notified and insistent on transport to emergency room for evaluation. We are doing so at this time . R64 is restless and we are unable to obtain a blood pressure. (R64) color remains gray and dusky. Is transport okay? At 11:54, V2 (Director of Nursing) responded, We have a standing order to transport to the emergency room if the POA wishes. We can write the order. On November 11, 2017 at 6:08 PM, the communication showed R64 was admitted to the ICU with [MEDICAL CONDITION] secondary to severe urinary tract infection and dehydration. The physician responded , Noted to the electronic communication on Sunday November 12, 2017 at 11:54 AM, no further orders received. R64's hospital discharge summary showed R64 was admitted to the hospital on November 11, 2017 with [DIAGNOSES REDACTED]. R64 was discharged on [DATE] to a different long term care facility with discharge [DIAGNOSES REDACTED]. R64 was discharged under hospice care.